Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
Due to Medicaid’s federal and state partnership, there are no statutes or regulations requiring state Medicaid agencies (and their managed care organizations) to use any specific coding set in the Medicaid program. State Medicaid agencies have the authority to adopt a code set for use by their plans and providers that best meets their program needs.
States will have a process to prevent payment for duplication of services. Local education agencies (LEA) and providers should consult the state Medicaid agency to see if services provided in schools and in the community are seen as duplicative or complementary. The state Medicaid agency can also provide information on the intersection between service limitations for a community provider such as an approved number of nursing hours and hours provided in school.
A diagnosis is not a federal requirement to bill Medicaid for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, however, a state Medicaid Agency may set their own requirements for local education agencies (LEA) to follow when billing for EPSDT services. A CMS Informational Bulletin (CIB) from August 18, 2022, provides information about leveraging Medicaid in the delivery of behavioral health services to youth and encourages states to avoid requiring a behavioral health diagnosis for the provision of EPSDT services. However, services must meet requirements for medical necessity, and all other Medicaid rules and regulations must be followed in any setting for Medicaid services.
There are two types of National Provider Identifiers (NPI): one for individual providers and one for organizational providers. Both types have specific criteria and requirements that need to be met. Inquiries related to obtaining an NPI number can be directed to AdministrativeSimplification@cms.hhs.gov.
1905(a) of the Social Security Act lists all benefit categories that may be covered by state Medicaid programs. The following link provides a list of the 1905(a) mandatory and optional state plan benefits: Mandatory & Optional Medicaid Benefits.
Yes, Screening, Brief Intervention, and Referral to Treatment (SBIRT) can be delivered in schools and reimbursed by Medicaid. SBIRT may be covered under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements and multiple 1905(a) benefit categories, such as preventive or rehabilitative services. The state Medicaid agency determines state plan coverage and payment options for these types of services.
The list of services on Medicaid.gov comes from 1905(r)(1)(B) of the Social Security Act, which specifies that screening services provided under EPSDT “shall at a minimum include—
(i) a comprehensive health and developmental history (including assessment of both physical and mental health development),
(ii) a comprehensive unclothed physical exam,
(iii) appropriate immunizations (according to the schedule referred to in section 1928(c)(2)(B)(i) for pediatric vaccines) according to age and health history,
(iv) laboratory tests (including lead blood level assessment appropriate for age and risk factors), and
(v) health education (including anticipatory guidance).”
This list of services is a minimum, not a comprehensive list of services that may be covered under EPSDT. The EPSDT benefit entitles most eligible Medicaid-enrolled children and adolescents to services and treatments that fit within any of the benefit categories of Medicaid-coverable services listed in section 1905(a) of the Social Security Act if medically necessary, as determined by the State, to “correct or ameliorate” identified conditions.
Therefore, schools and other providers may perform and bill for some EPSDT services without providing all of the minimum services listed in 1905(r)(1)(B). EPSDT services include comprehensive examinations, vaccinations, screening for common childhood health conditions, screening and treatment for mental health conditions, and other services.
The State Medicaid agency or state laws related to consent protocols and procedures would apply. Please consult the relevant state agencies or your organizational legal counsel.
When conducting medical/health assessments/evaluations as part of the development of an IEP or IFSP, Code 4C. Direct Medical Services – Covered on a Medical Plan of Care, Not Covered as IDEA/ IEP service, is the correct code. Because the services are not due to an IEP, but rather result in an IEP, Code 4C is utilized instead of Code 4B. Code 4C should be used when providing direct medical services when documented on a medical plan other than an IEP/IFSP or where medical necessity has been otherwise established. These direct services may be delivered to an individual and/or group in order to ameliorate a specific condition and are performed in the presence of the student(s).
No, IEP meetings and the initial creation of an IEP should be coded under Code 3. School Related and Educational Activities. Page 134 of the Comprehensive Guide defines Code 3 as including: “Developing, coordinating, and monitoring the IEP for a student, which includes ensuring annual reviews of the IEP are conducted, parental sign-offs are obtained, and the actual IEP meetings with the parents.”
IEP meetings are performed to meet the IDEA statute and regulations, and therefore are educational in nature. When health professionals attend an IEP meeting, the focus of the meeting is on a student’s needs that impact their educational attainment, so these activities continue to be classified as educational. Education is not the same cost center as Medicaid allowable activities and the costs are therefore excluded from Medicaid reimbursement.
However, it is important to note that Medicaid will reimburse for assessments to evaluate the child’s medically necessary treatment needs when performed by a practitioner whose scope of practice includes referrals for treatment.