Billing

Head Start; Women, Infants, and Children (WIC); and Public Health Agency Billing for Fluoride Varnish Application (FVA)

Use the following codes for Head Start, WIC, and Public Health agency billing:

CPT code 99188: Trained licensed or certified health care professionals in a community setting under the direct supervision of a treating physician or other qualified health care professional.
CDT code D1206: Trained licensed or certified health care professionals in a community setting under the direct supervision of a treating dentist.

FVA Billing by Primary Care Providers

Primary care providers (physicians or other qualified health care professionals) and trained clinical staff bill using CPT code 99188.

Primary care providers bill FVA on the same claim as other Child and Teen Checkup (C&TC) services. The Minnesota Health Care Programs (MHCP) reimbursement rate is per procedure (not per tooth). The payment for FVA is in addition to the C&TC “bundled rate” for a complete C&TC screening visit.
When providing FVA at other pediatric visits, bill FVA on the same claim as the other pediatric services.
FVA is limited to four per 365 days.

Refer to the Non-Dental Health Provider section of the DHS Provider Manual for specific billing instructions or for more information.

Silver Diamine Fluoride (SDF)

The American Medical Association (AMA) has approved a code for health care professionals to receive reimbursement for the application of SDF to arrest dental caries lesions without the provision of restorative care.

Where there is visible need identified during the open-mouth exam at a C&TC visit, providers may apply this solution to a tooth or teeth.
Obtain informed consent and provide SDF education

SDF Billing by Primary Care Providers

Use CPT code 0792T: Primary care providers (physician or other qualified health care professionals) and trained clinical staff
Primary care providers bill SDF on the same claim as the other C&TC services. MHCP reimbursement rate is per tooth with a given tooth number billed once per six months. There is no limit on the number of teeth that may be treated per day.
The payment for SDF, when applied during a C&TC visit, is in addition to the bundled rate.

Vision Screening

An NCCI procedure-to-procedure (PTP) edit pairs preventive visit CPT codes in the range of 99381 – 99397 with vision screening. You may receive the NCCI edit when submitting claims for vision screening with CPT code 99173. These edits have a Correct Coding Modifier Indicator of “1” and, therefore, bypass the PTP edit if you correctly add a PTP-associated modifier. See the Minnesota National Correct Coding Initiative (NCCI) page for information about modifiers.

Bill instrument-based vision screening using CPT codes 99174 or 99177.

Screening Exceptions

PrimeWest Health recognizes that in some situations, it is not possible or appropriate to require C&TC providers to complete certain components of the C&TC screening as outlined in the Schedule of Age-Related Screening Standards. According to Administrative Uniformity Committee (AUC) recommendations, use the following billing guidelines for the situations listed in the claim guideline exceptions table when screening component(s) cannot be performed or an initial screening is not appropriate.

If a screening component is refused by a parent or young adult, provide education about the risks and benefits of the refused component.

Claims submitted using the following guidelines for an exception identified below will be recognized as completed C&TC claims.

Follow all billing policy requirements for submitting a C&TC screening claim
Report one of the HIPAA-compliant referral codes (ST, NU, AV, S2)
Use the claim reporting and medical documentation for the exception reasons as appropriate

Exception Reason	Situation	Claim Reporting and Medical Documentation
Condition already identified (screening is not medically necessary)	Out of provider’s control: Child has a diagnosis of a hearing or visual impairment Child wears/has new glasses (identified visual impairment) Completing a vision screening may not be indicated at this time Child/parent has been referred for ongoing monitoring or treatment Child has been diagnosed as having autism or developmental delay Completing a developmental screening may not be indicated Child/parent has been referred for ongoing treatment and/or services for the condition	Maintain specific documentation of the diagnosis in the medical record of the child Report the correct CPT code for the screening component on the claim Enter an additional diagnosis code identifying the condition Enter $0.00 or $0.01 as the submitted charge
Contraindication (service recently performed elsewhere)	Out of provider’s control: Hearing or vision screening performed at school Mental health screening was recently performed (within last year) for youth age 12 and over	Request and review test results at the time of the visit. If results are within acceptable limits, add specific documentation and maintain a copy of the test results in the medical record of the child. Report the correct CPT code for the screening component on the claim Enter $0.00 or $0.01 as the submitted charge
Service is not applicable	Child’s teeth have not yet erupted; therefore, fluoride varnish application (FVA) may not be provided.	Report the correct CPT code for the screening component on the claim Enter $0.00 or $0.01 as the submitted charge
Service recently provided elsewhere	FVA was provided in another setting, such as the dental home or public health setting, within the last 30 days	Document date FVA was provided in the medical record Report the correct CPT code for the screening component on the claim Enter $0.00 or $0.01 as the submitted charge
Parent or young adult (or adolescent, for HIV screen) declined	Rescheduling for a later date is not feasible Against personal or religious belief of the parent or family	Provide specific documentation of the parent refusal Report the correct CPT code for the screening component on the claim Enter $0.00 or $0.01 as the submitted charge
Parent refusal	Rescheduling for later date is feasible (parent is willing) Parent indicates he/she does not want the component completed because of time constraints or mood of the child	Reattempt the screen component within 30 days If reattempting to screen, wait to bill the C&TC screening until all components are completed Bill using the two separate dates if within the same month If the second screening attempt crosses over to a new month, use the date the C&TC screening was finally completed
Unsuccessful attempt (child uncooperative)	Rescheduling for a later date is not feasible A valid attempt was made to complete the service	Provide specific documentation of the unsuccessful attempt Report the correct CPT code for the screening component on the claim Add modifier 52 to the claim Enter the usual and customary charge
Unsuccessful attempt (child uncooperative)	Rescheduling for later date is feasible The child is not cooperating well enough to allow component to be completed at that time A diagnosis has been found to justify that performing the component would further upset the child (e.g. child has ear infection, pink eye)	Reattempt the screen component within 30 days If reattempting to screen, wait to bill the C&TC screening until all components are completed Bill using the two separate dates if within the same month If the screening crosses over to a new month, use the date the C&TC screening was finally completed
Screening instrument not reviewed	A developmental screening instrument was sent to parents but not returned for review at the time of the C&TC screening	Do not report the developmental screening code as a separate line item on the claim OR Wait to bill the completed screening until the parent report is received and reviewed Bill using the two separate dates (the date the C&TC screening was started and the date the completed screening instrument was reviewed) if within the same month. If the review of the screening instrument, crosses over to a new month, use the date the C&TC screening was finally completed

Non-Covered Services

MHCP does not cover the following services under C&TC:

Clinic visits or well-child screenings that do not meet C&TC screening requirements may be covered through other MHCP services such as physician services
Services provided by a non-C&TC provider
Do not bill counseling and risk factor reduction E&M codes with comprehensive preventive medicine E&M codes. These codes already include counseling, anticipatory guidance and risk factor reduction as part of the comprehensive exam.

Authorization

C&TC screening services and screening components do not require authorization. For diagnosis and treatment services that may require authorization, refer to the MHCP Provider Manual's Authorization section. For clinic or physician services provided to a child not included in the C&TC screening benefit, refer to the MHCP Provider Manual's Physician Services section.

C&TC Screening With an E/M Service

If, at the time of the C&TC screening, a significant, separately identifiable E/M service is provided, that E/M code must be billed with the modifier 25. Documentation in the health record must support key components of billed E/M services. Follow CPT instructions for appropriate coding.

Referrals

A referral for C&TC reporting purposes indicates the child needs to be seen again for further assessment, diagnosisor treatment of a problem, or a concern that was identified during the C&TC screening. Include the appropriate referral code on the C&TC claim.

The referral can be made to the screening provider or to another provider, and can be provided on the same day as the C&TC visit. Bill the referral services visit on a different claim that the C&TC even if the visit occurs on the same day as the C&TC screening.

C&TC Screening Service Billing/Coding

For more information on billing, please see electronic data interchange (EDI) requirements in Claims Submission.

Reimbursement for C&TC screening services is dependent upon referral codes on the 837P claim format. The four C&TC referral codes (AV, ST, S2, and NU) are used to do the following:

Identify the claim as a complete C&TC screening
Ensure appropriate provider reimbursement
Identify referrals for public health follow-up
Collect Federally required data

PrimeWest Health also requires the S0302 code as a line item on the claim form. By submitting the S0302 code, the provider indicates to PrimeWest Health that a full C&TC screening was completed.

Follow the Minnesota Child and Teen Checkups (C&TC) Schedule of Age-Related Screening Standards (DHS-3379) to identify required C&TC screening components for the periodic visit, including a referral to a dentist.

Health Insurance Portability and Accountability Act (HIPAA)-Compliant Referral Condition Codes

C&TC HIPAA-compliant referral condition codes (also called referral codes) indicate a referral was made as a result of the C&TC screening. C&TC claims must list the most appropriate HIPAA-compliant referral condition code: ST, S2, AV, or NU.

Billing processes include complying with HIPAA and PrimeWest Health system and data requirements. This section includes the following information:

Two-character C&TC referral codes and HIPAA definitions
How to bill a complete C&TC screening electronically
Using C&TC referral codes appropriately
C&TC referral code priority chart
Additional billing information for developmental and social/emotional/mental health screening

DHS provides referral codes through a secure data system to C&TC programs throughout Minnesota (local Public Health and Tribal Health) under contract with DHS. C&TC program staff provide outreach communications and assistance to families of children younger than age 11 requiring further evaluation, diagnosis, and treatment for a condition identified during the C&TC screening visit.

Refer to the HIPAA Compliant C&TC Referral Codes Fact Sheet for more information.

How to Bill a Complete C&TC Screening Electronically

The C&TC referral code you choose pertains to the entire claim and is entered at the claim (header) level in loop 2300. Different C&TC referral codes cannot be used on different lines of the same claim. Previously, providers could use more than one referral code on a claim. The Federal HIPAA format allows only one C&TC referral code to be used per claim.

When billing for a complete C&TC screening, the claim should not include additional non-C&TC procedures. When procedures in addition to the completed C&TC screening components are performed at the same visit (e.g., tympanometry), bill the additional procedures on a separate claim, use modifier 25, and do not include a C&TC referral code on the non-C&TC claim.

PrimeWest Health receives EDI 837 claims from ClearConnect, ClaimLynx, McKesson, MedAvanti (a.k.a. ProxyMed), CareMedic Emdeon (a.k.a. Web-MD/Envoy), and receives cross-over claims from CMS.

To set up electronic claims processing, please call the PrimeWest Health Provider Contact Center at 1‑866-431-0802 (toll free). Also refer to Claims & Payment for more information. Review MN–ITS User Manual – Billing for Child and Teen Checkups (C&TC) Services or the Minnesota Administrative Uniformity Committee (AUC) Companion Guides for ANSI ASC X12 837P requirements.

Field	Enter
CLM12 – Special Program Indicator: Indicates a C&TC screening was completed	01 for EPSDT/Child Health Assessment Program (CHAP)
CRC02 – Certification Condition Indicator: Indicates whether a referral was made	N for “NO” if a referral was not made Y for “YES” if a referral was made
CRC03 – Condition Indicator: Indicates the outcome of the screening	One of the four new two-character C&TC referral codes (AV, ST, S2, and NU)

Two-Character HIPAA-Compliant Referral Condition Codes and Definitions

Use the most appropriate referral code from the following table:

HIPAA-compliant referral condition code	Use this referral condition code for billing when a C&TC screening results in one of the following:
ST (new diagnosis or treatment service requested)	One or more referrals were made (ST) Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service –or– Patient is scheduled for another appointment with the screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service
S2 (continue current services or treatment)	The patient is currently under treatment for a diagnostic or corrective health problem(s)
AV – declined referral (referral recommended but it was declined)	One or more referrals were made and the patient (or parent or guardian) declined one or more of the referrals (AV)
NU (no referral – not used)	No referral(s) given (NU) If only a verbal dental referral was made for preventive dental health care

Additional Billing Information for Developmental and Social-Emotional or Mental Health Screening

Developmental and social-emotional or mental health screenings can be billed as separate line items on a C&TC claim if standardized tools are used to conduct the assessments. Standardized parent-questionnaire assessment tools are acceptable means of assessment. If both a developmental and a social-emotional or mental health screening are conducted (using appropriate standardized instrument), both assessments can be billed as line items on the claim form.

When an Autism Spectrum Disorder (ASD)-specific screening is completed in addition to another developmental screening using two separate standardized screening instruments, bill for the ASD-specific screening and the developmental screening on the C&TC claim.

The appropriate CPT codes are as follows:

CPT code 96110 – Developmental screening with a standardized instrument
CPT code 96110 and modifier U1 (for the ASD-specific screening)
CPT code 96127 – Social-emotional or mental health screening with a standardized instrument

Do not bill developmental and social-emotional or mental health screenings as a separate service performed during a C&TC when no standardized screening instrument was used.

HCPCS Code S0302

PrimeWest Health does not require the use of HCPCS code S0302 and considers this code as informational only.

If HCPCS code S0302 is reported without a HIPAA-compliant referral condition code on that claim, the claim will be denied.

DHS will recognize a claim as a C&TC screening only when a HIPAA-compliant referral condition code is entered on the claim.

PW_11-19_529
Updated_12/16/2025

Medical, Dental & Pharmacy