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7/15/2024

How to Screen and Bill for Anemia with Highmark Wholecare

Anemia screening is an important aspect of health care in children and infants. The American Academy of Pediatrics (AAP) and the American Family Physician (AFP) identify anemia screening as a universal screening. Despite this recognition, iron deficiency and iron deficiency anemia continue to be of concern and can have adverse effects on neurodevelopment in infants and children.

Highmark Wholecare Providers should conduct anemia screenings at the following ages:

  • Between 9 and 12 months of age.
  • Risk assessment for anemia at 4 months of age, 15 months of age, and then each well child visit thereafter, as recommended by the AAP.
  • For females after 12 years of age once menses starts.

To review CDC Guidelines, please refer to Morbidity and Mortality Weekly Report (MMWR) on the CDC website. 

Billing

All EPSDT screening services must be reported with the age-appropriate evaluation and management code along with the EP modifier.

  • 1 month to 11 month EPSDT visit CPT Code is 99381 or 99391
  • 12 month to 4 year EPSDT visit CPT Code is 99382 or 99392
  • 12 year to 17 year EPSDT visit CPT Code is 99384 or 99394
  • 18 year through 20 EPSDT visit CPT Code is 99385 or 99395

Provider should choose most appropriate test:

  • The CPT code for spun Hematocrit is 85013
  • The CPT code for Hemoglobin is 85018

Modifier:

  • 90 when applicable
  • When laboratory procedures are performed by a party other than the treating or reporting physician, use CPT code plus modifier 90 Reference Outside Lab. This modifier is used to indicate that although the physician is reporting the performance of a laboratory test, the actual testing component was a service from laboratory.

For questions regarding the EPSDT program, please contact EPSDTinfo@HighmarkWholecare.com.

References:

 

These codes are not all encompassing and use does not guarantee payment. They are intended as a guide to provide education around appropriate screenings and coding as part of the EPSDT program.

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The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.