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Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Quick Reference

Content to reflect American Academy of Pediatric, CMS, and state guidance.

Heritage Health - Nebraska Total Care 

Nebraska Total Care strives to provide quality healthcare to our membership as measured through Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and Healthcare Effectiveness Data and Information Set (HEDIS) outcome measures. The information on this page is to assist your practice with increasing your EPSDT participation and screening rates.

This page describes key EPSDT exam components and provides guidance on how to bill appropriately. Please always follow the State and CMS billing guidance and ensure the EPSDT codes are covered prior to submission.

EPSDT Billing Guide (PDF)

EPSDT screening guidelines are taken from recommendations by American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry (AAPD), and the Centers for Medicare & Medicaid Services (CMS). Screening components during each visit will depend on the child’s age and the state periodicity schedule.

  • Comprehensive health and development history (including both physical and mental health)
  • Unclothed physical exam
  • Developmental and behavioral assessment
  • Assessment and provision of immunizations as appropriate for age and health history
  • Assessment of nutritional status
  • Vision testing
  • Hearing testing
  • Laboratory procedures appropriate for age and population
  • Oral health risk assessment on all children at preventive visits, and dental referral according to the state dental periodicity schedule and requirements
  • Anticipatory guidance and health education
  • Other necessary health care diagnostic services and treatment to correct and ameliorate defects and physical and mental illnesses and conditions discovered by the screening services

Always follow state guidance and refer to the Nebraska provider manuals.

  • Using a template is recommended to ensure appropriate documentation. For tools for documentation and additional information please refer to American Academy of Pediatrics and Bright Futures. 
  • A provider may bill for a sick and EPSDT visit on the same date of service when modifier 25 is used and documentation supports the sick visit was significant and separately identifiable. 
  • A Lead Risk Assessment is mandatory for children at 6 months and 72 months.