Provider Notice issued 02/10/04

Billing for Screenings Under the Healthy Kids Program

The purpose of this notice is to provide clarification on the billing of objective screenings and assessments (e.g., hearing screenings, vision screenings and developmental screenings ) under the department's Healthy Kids program, and to advise providers of the department's acceptance of the Guidelines for Adolescent Preventive Services (GAPS) adolescent screening tool. Please refer to the Handbook for Providers of Healthy Kids Services, Chapter HK- 200, for a complete listing of the objective screening instruments recognized for reimbursement by the department.

As a federally funded program, the department has reporting requirements that are not applicable to other payers. The detailed billing of services under the Healthy Kids program is one of these requirements. It is our understanding that, while the department requires providers to bill the objective screenings separately, most third party payers have an all-inclusive "bundled" rate for recommended preventive well child exams that include the objective screenings and assessments. As a result, many providers do not have an established usual and customary rate solely for objective screenings.

In order to receive reimbursement from the department for objective hearing, vision and developmental screenings, as well as, the administration of immunizations, providers are encouraged to establish a usual and customary rate for each procedure. This could be accomplished by "unbundling" the services, or if the department is the only payer for which you are billing the screenings separately, the department's rate could be used as the usual and customary charge.

The department is especially interested in promoting vision screenings to detect ocular disorders in children ages 3-5 that could result in conditions such as amblyopia. By increasing the occurrence of screenings in this population, the department hopes to promote medical intervention to prevent the loss of vision that could otherwise occur in children with undiagnosed and untreated pathology.

Similarly, the department, in conjunction with the Illinois Chapter of the American Academy of Pediatrics, is recommending providers conduct periodic objective developmental screenings as an adjunct to the anticipatory guidance that is normally part of a well child visit. For more information about developmental screenings, such as the list of objective developmental screening tools approved for reimbursement by the department, consult the Handbook for Providers of Healthy Kids Services , available on the department's Web site at <http://www.dpaillinois.com/handbooks/>.

Effective immediately, the department will also recognize the American Medical Association's (AMA) Guidelines for Adolescent Preventive Services (GAPS ) questionnaire as an approved risk assessment tool eligible for reimbursement. Reimbursement will be made for completion of either the Younger Adolescent Questionnaire or the Middle-Older Adolescent Questionnaire. The Handbook for Providers of Healthy Kids Services, Chapter HK- 200, will be updated to include the GAPS questionnaire . The GAPS questionnaire, as well as the GAPS Recommendations Monograph, is available on the AMA's Web site at <www.ama-assn.org>. Specifically, these documents are posted under "Public Health" submenu accessible through the section for physicians or the site map.

The Illinois Chapter of the American Academy of Pediatrics is available to assist providers who wish to learn more about developmental screening tools or adolescent health resources. Contact the Illinois Chapter at 312-733-1909 or 312-733-6207 or e-mail info@illinoisaap.com

Questions regarding this notice should be directed to the Bureau of Comprehensive Health Services at 217-782-5565.

Anne Marie Murphy, Ph.D.
Administrator
Division of Medical Programs