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EPSDT Clinical & Operational Guidelines


UPMC for You adopted Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements based on changes implemented by the Pennsylvania Department of Human Services (DHS) in 2008.

UPMC for You and DHS recognize the importance of comprehensive childhood screenings and providing appropriate and timely follow‐up diagnostic treatment services. We encourage and support physicians in performing EPSDT services. UPMC for You developed EPSDT Clinical and Operational Guidelines to explain our requirements for payments and to provide sample billing instructions. We are also including a sample of the quarterly EPSDT reports, which were implemented in January 2009, and the 2009 immunization schedule.

Important points to know about the UPMC for You EPSDT requirements:

  • Providers can perform and bill for a sick visit and an EPSDT visit on the same date of service in the following circumstances:
    • When it is determined that the illness or injury that led to the sick visit does not impede the ability to complete a well-child visit and
    • The child is due for an EPSDT visit

    Correct use of Modifier 25, which indicates when a significant and separately identifiable service is delivered, will result in reimbursement for both services.
  • The EPSDT service will be paid in full if all of the appropriate services are rendered for the correct EPSDT periodicity visit, per the UPMC for You periodicity chart. Appropriate use of the 52 modifier will not result in a reduced payment. Properly billed claims with the 52 modifiers will receive payments in full.
  • For services that can be provided, but a 52 modifier was used, the provider must complete the service at the next screening.
  • Incorrect billing will result in a reduced rate.

Important information and forms: