HIPAA: EPSDT Services Code Conversion
HIPAA-mandated changes to billing requirements for Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Services became effective on September 1, 2018.
HIPAA is the acronym for the Health Insurance Portability and Accountability Act, which was passed by Congress in 1996. In addition to eliminating the use of Level III local codes, HIPAA does the following:
- Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs.
- Reduces healthcare fraud and abuse.
- Mandates industry-wide standards for health care information on electronic billing and other processes.
- Requires the protection and confidential handling of protected health information.
California has historically used thousands of HCPCS Level III or local codes (also known as interim codes) for billing and reimbursement of services and supplies. National codes, such as HCPCS Level II codes, are typically more specific in nature compared to local codes. Using HIPAA-compliant HCPCS Level II codes will:
- Simplify processes and decrease the costs associated with payment for health care services.
- Improve the efficiency and effectiveness of the health care system and decrease administrative burdens on providers (for example, medical practices, hospitals and health care plans).
- Provide standardization and consistency in medical service coding.
- Characterize a general administrative situation, rather than a medical condition or service, by using non-clinical or non-medical code sets.
The use of HIPAA-compliant HCPCS Level II codes are required to bill for the face-to-face (one-on-one) visit with the patient on or after September 1, 2018.
The claim may consist of the following:
- HCPCS Level II national code with modifier EP or
- Revenue Code and HCPCS Level II national code with modifier EP
This code conversion replaces non-HIPAA-compliant HCPCS Level III local codes with national HIPAA-compliant HCPCS Level II procedure codes. National HCPCS Level II codes identified in combination with an EP modifier will allow for the distinction of services rendered to adults from services rendered to children and adolescents.
The approved codes can be found on the crosswalk on the EPSDT Services section of the HIPAA: Code Conversions page. The following Frequently Asked Questions (FAQs) will provide an overview of the affected codes in this conversion.
What does the conversion from HCPCS Level III local codes to HCPCS Level II codes mean?
The conversion from the HCPCS Level III local codes to HIPAA-compliant HCPCS Level II codes means providers who currently submit HCPCS Level III local codes when billing for the EPSDT services described below are required to submit claims using the specified HCPCS Level II national codes effective for dates of service on or after September 1, 2018.
Which local codes will convert to National codes?
Two local Z-codes were replaced with T-codes for EPSDT services:
Z5868 (pediatric day health care) converted to T1026 (intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, medical and psychosocial impairments, per hour)
Z5830 (onsite investigation to detect source of lead contamination rendered by local health department or comprehensive environment agencies) converted to T1029 (comprehensive environmental lead investigation, not including laboratory analysis, per dwelling)
How will the conversion impact claims billed with dates of service before September 1, 2018?
Continue to bill with HCPCS Level III local codes for dates of service on or before August 31, 2018. Begin billing HIPAA-compliant HCPCS Level II codes for dates of service on or after September 1, 2018.
Modifier codes are used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Modifier codes help further describe a procedure code without changing its definition.
Modifier EP (service provided as part of Medicaid EPSDT) allows for the distinction between services rendered to adults from services rendered to children and adolescents.
The EP modifier is applicable for dates of service on or after September 1, 2018.
A revenue code identifies specific accommodations, ancillary service, or unique billing calculations or arrangements. Revenue codes are four digits and accompany CPT Category I and HCPCS Level II national procedure code(s) billed on a claim.
Will a revenue code be required when billing claims?
Revenue codes are not required on CMS-1500 claim forms or ANSI 837P transactions.
Effective January 1, 2019, a four-digit revenue code must be included on Outpatient claims billed on paper UB-04 claim forms or ANSI 837I for electronic billing.
Outpatient claims with dates of service on or after January 1, 2019, submitted on paper UB-04 claim forms or ANSI 837I transactions with missing, incomplete or invalid revenue codes will be denied.
How will this conversion affect my approved TARs and claims for Pediatric Day Health Care?
All Treatment Authorization Requests (TARs) processed and approved on or before August 31, 2018, may be processed using the current HCPCS Level III local code Z5868. Claims for these TARs may be submitted with HCPCS Level III local code Z5868 until the end date of that TAR.
TARs for Z5830 are not required.
What do I do about claims and TARs billed for Pediatric Day Care after the code conversion?
TARs originated on or after September 1, 2018, must be submitted using the national HCPCS Level II code T1026. TARs approved beyond September 1, 2018, with HCPCS Level III local codes will be deferred for correction. Claims for these TARs must be submitted using national HCPCS Level II codes.
TARs are not required for T1029.
Can I bill EPSDT services for recipients over 21 years of age?
Claims for outpatient and Medi-Cal EPSDT services require medical justification for recipients greater than 21 years of age. If medical justification is not attached, the claim will be denied with Remittance Advice Details (RAD) code 0184: This procedure requires medical justification. The documentation supplied is insufficient or no remarks/attachments are provided.
Who can I contact if I have additional questions or concerns?
Providers may request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border Providers and Out-of-State Billers billing for In-State Providers call 1-916-636-1200. Providers calling from outside of California call the Out-of-State Provider Unit at 1-916-636-1960 from 8 a.m. to 12 p.m. Monday through Friday, except holidays.
For electronic claim submission questions the Computer Media Claims (CMC) Help Desk can be accessed by calling the TSC at 1-800-541-5555 and select the option Point of Service (POS), Internet, Lab Service Reservation System (LSRS) and CMC inquiries.
All other questions for the EPSDT Services code conversion may be submitted via email to CAMMISCodeConversion@dxc.com.