Sunday, May 1, 2011



We haven’t filed claims with N and NU ESPDT codes for physical examination procedures.  Hence we received denial stating “Invalid/need referral check codes”


For Physical examination codes (99381-99395) we must enter Child Check up code “N” and its valid referral code “NU” in EPSDT fields for Medicaid insurance.


Based on the denials received from Medicaid, we scrutinized the reason for the given denials and found per Medicaid rules to file Physical Examination codes along with N and NU ESPDT codes to have the claims reimbursed.  Hence the claims were refiled with the same and got reimbursement on the same.  Henceforth the rule was set towards the Charge entry executives file these procedures with ESPDT codes for Medicaid without fail.


A complete physical examination must be performed at each well child visit. Infants are to be totally unclothed and older children must be undressed and suitably draped. If the patient is an adolescent or young adult and the examination requires inspection or palpation of anorectal or genital areas and/or the female breast, a chaperone is recommended. The use of a chaperone should be a shared decision between the patient and the PCP. If the patient declines the use of a chaperone, the provider should document this fact in the medical record. The purpose of the well child examination is to promote health, detect medical problems, and to counsel in order to prevent injury and future health problems. The physical examination also provides opportunities to educate children, adolescents, and their parents/guardians about the body and the growth and development process. The physical examination must be comprehensive and appropriate for the infant’s, child’s, or adolescent’s age, gender, and developmental status, and should build on the history gathered during previous medical and well child visits. The provider should review the scope and findings of the examination with the patient and parents/guardians at the completion of the examination. This review should be documented in the medical record.

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