Benefits include hearing aids and other assisted devices, auditory training in the use of hearing aids, therapy for children with hearing impairments, and family-focused home-based early language intervention for children, birth to three years of age , with hearing loss through the Colorado Home Intervention Program CHIP.
Vision diagnostic and treatment services may be performed by an ophthalmologist or optometrist. Referral is not required for vision care. Single and multifocal vision lenses and frames, as well as repair or replacement of broken lenses or frames, are benefits of EPSDT and may be provided by an ophthalmologist, optometrist, or optician. Contact lenses are available in some medically necessary situations and require prior authorization.
Complete billing instructions for vision services are included in the vision billing manual. Other children's health care services are billed on the CMS , using national standard codes.
The codes are used for submitting claims for services provided to Health First Colorado members and represent services that may be provided by enrolled certified Health First Colorado providers. The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.
Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies DMEPOS when used outside a physician's office.
Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits. If there is no time designated in the official descriptor, the code represents one unit or session. Providers should regularly consult monthly bulletins on the Provider Services Bulletins web page.
To receive electronic provider bulletin notifications, an email address can be entered into the Web Portal in the MMIS Provider Data Maintenance area or by completing and submitting a publication preference form. Bulletins include updates on approved procedures codes as well as the maximum allowable units billed per procedure.
Always remember that any code or service can be requested, even if the code is not open in the fee schedule or listed in this or other billing manuals. The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the EPSDT claim form. For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.
Colorado Official State Web Portal. Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems. These codes must be used in conjunction with diagnosis codes for a well- child exam including , Note: Used in conjunction with the appropriate diagnosis codes excluding the well-child diagnosis codes: Z Example: A Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year.
Example: for July 1, Place an X in the appropriate box to indicate the sex of the member. If there is no signature on file, leave blank or enter "No Signature on File". Enter the date the claim form was signed. Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year.
If the member is still hospitalized, the discharge date may be omitted. This information is not edited. Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services.
Do not complete this field if any laboratory work was performed in the office. Practitioners may not request payment for services performed by an independent or hospital laboratory. Enter applicable ICD indicator. List the original reference number for resubmitted claims. When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field. The paper claim form allows entry of up to six detailed billing lines.
Fields 24A through 24J apply to each billed line. Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing. Each claim form must be fully completed totaled. Do not file continuation claims e. The field accommodates the entry of two dates: a From date of services and a To date of service.
Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: for January 1, Enter a Y for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life- threatening condition or one that requires immediate medical intervention. If a Y for YES is entered, the service on this detail line is exempt from co-payment requirements.
Enter the HCPCS procedure code that specifically describes the service for which payment is requested. CPT is updated annually.
Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form. Claim diagnosis code s must identify a condition unrelated to the surgical procedure. Professional component Use with diagnostic codes to report professional component services reading and interpretation billed separately from technical component services.
Report separate professional and technical component services only if different providers perform the professional and technical portions of the procedure. Read CPT descriptors carefully. Do not use modifiers if the descriptor specifies professional or technical components.
Anesthesia by surgeon Use with surgical procedure codes to report general or regional anesthesia by the surgeon. Local anesthesia is included in the surgical reimbursement. Bilateral procedures Use to identify the bilateral second surgical procedure performed at the same operative session.
Read CPT descriptions carefully. Do not use modifier if the procedure descriptor states "Unilateral or bilateral" services. Multiple Procedures Use to identify additional procedures that are performed on the same day or at the same session by the same provider.
Do not use to designate "add-on" codes. Distinct Procedural Services Use to indicate a service that is distinct or independent from other services that are performed on the same day.
These services are not usually reported together but are appropriate under the circumstances. This may represent a different session or member encounter, different procedure or surgery, different site or organ system or separate lesion or injury.
Use to identify unrelated services by the operating surgeon during the postoperative period. Assistant surgeon Use with surgical procedure codes to identify assistant surgeon services.
Note: Assistant surgeon services by non-physician practitioners, physician assistants, perfusionists, etc. Item or services statutorily excluded or does not meet the Medicare benefit. Use with podiatric procedure codes to identify routine, non-Medicare covered podiatric foot care. Modifier -GY takes the place of the required provider certification that the services are not covered by Medicare. The Medicare non-covered services field on the claim record must also be completed.
Specific required documentation on file Use with laboratory codes to certify that the laboratory's equipment is not functioning, or the laboratory is not certified to perform the ordered test. The -KX modifier takes the place of the provider's certification, "I certify that the necessary laboratory equipment was not functioning to perform the requested test", or "I certify that this laboratory is not certified to perform the requested test. Inpatient newborn care billed using mother's State ID and birth date Use to identify inpatient physician services rendered to newborn infants while the mother remains in the hospital.
Services provided to a hospitalized newborn after the mother's discharge must be submitted using the Health First Colorado ID number assigned to the child. Postoperative Management only Use with eyewear codes lenses, lens dispensing, frames, etc.
Benefit for eyewear, including contact lenses, for members over age 20 must be related to surgery. Modifier takes the place of the required claim comment that identifies the type and date of eye surgery.
The provider must retain and, upon request, furnish records that identify the type and date of surgery. Enter the diagnosis code reference letter A-L that relates the date of service and the procedures performed to the primary diagnosis. At least one diagnosis code reference letter must be entered.
When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.
This field allows for the entry of 4 characters in the unshaded area. Enter the usual and customary charge for the service represented by the procedure code on the detail line.
Do not use commas when reporting dollar amounts. More information is available on the Information for Medi-Cal Providers resource document. Subscribers receive subject-specific emails for urgent announcements and other updates shortly after they post to the Medi-Cal website.
To subscribe, please click on this website link. Other health and mental health plan letters — These letters are issued to Medi-Cal managed care plans that serve Medi-Cal beneficiaries, and include requirements for providing services under EPSDT. Left Column Content Row1. Right Column Content Row1. Left Column Content Row2.
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