Module 5: Form CMS-416 Specifications – Lines 12f and 12g

Module 5: Form CMS-416 Specifications – Lines 12f and 12g


Welcome to Module 5, a review of Form CMS-416 Specifications for Lines 12f and 12g. This module is part of the CMS web-based training for Form CMS-416 Dental Data Reporting. Please visit the CMS Web-Based Training homepage at Medicaid.gov to find links to modules covering additional topics. There, you will also find a document that contains links to all the resources mentioned in this module. For questions about the Form CMS-416 or the Oral Health Initiative, you can access the complete Form CMS-416 reporting instructions on the Early and Periodic Screening, Diagnostic, and Treatment (or EPSDT) page at Medicaid.gov, or email the EPSDT Technical Assistance Mailbox at [email protected] This module will cover content related to Form CMS-416 specifications on lines 12f and 12g. After completing this module, you will understand how to count the number of individuals eligible for EPSDT (also known as eligibles) who received: An oral health service provided by a non-dentist (which corresponds to Line 12f). And any dental OR oral health services (which correspond with Line 12g). The content covered in this module includes: The importance of Lines 12f and 12g. The difference between an oral health service and a dental service. Determining the correct age range in which to report based on date of birth. And data quality checks for Lines 12f and 12g. Let’s talk more about who is included in lines 12f and 12g. Line 12f reflects the number of eligibles who received an oral health service, and Line 12g reflects the number of eligibles who received either an oral health service or a dental service. The Form CMS-416 instructions define eligibles as “Individuals under the age of 21 enrolled in Medicaid or a Children’s Health Insurance Program (or CHIP) Medicaid expansion program determined to be eligible for EPSDT services.” For more information on how to determine who is an “eligible” for purposes of reporting on the Form-CMS 416, see Module 3 of this series. Remember that the dental and oral health services data reported on the Form CMS-416 are the number of people, not the number of services provided. This means that one person might be counted in multiple Lines, since it is possible, in fact quite typical, that an individual will receive more than one type of dental or oral health service in a given year. However, within a single Line, make sure to deduplicate your data so that an individual is only counted once on any given Line. This is especially important when summing lines 12a (any dental service) and 12f (oral health services) together into line 12g (any dental or oral health service). As I’ve said: Line 12f counts the number of eligibles who received an oral health service, and Line 12g reflects the number of eligibles who received a dental or oral health service. Now let’s review a few definitions: The Form CMS-416 instructions define eligibles as “Individuals under the age of 21 enrolled in Medicaid or a Children’s Health Insurance Program (or CHIP) Medicaid expansion program determined to be eligible for EPSDT services.” For the purposes of Form CMS-416 reporting, oral health services are defined as services provided by any qualified health care practitioner or by a dental professional who is neither a dentist nor providing services under the supervision of a dentist. Also, the term dental services refers to services provided by or under the supervision of a dentist. Supervision is a spectrum and includes, for example, direct, indirect, general, collaborative or public health supervision as provided in the state’s dental practice act. In Module 4 we learned how to calculate eligibles who receive any type of dental service as well as different types of dental services – preventive, treatment, diagnostic. These correspond with Lines 12a, 12b, 12c, and 12e, respectively. In addition we learned how to calculate those that receive sealants on molars (which corresponds to Line 12d). Now let’s walk through how these lines relate to one another First, we start with Dental Services. Line 12a (which is the Total eligibles receiving any dental services) is the unduplicated count of Line 12b (the Total eligibles receiving preventive dental services), line 12c (the Total eligibles receiving dental treatment services) and line 12e (the total eligibles receiving diagnostic dental services). Next we capture Oral Health Services from line 12f (the total eligibles receiving oral health services provided by a non-dentist provider). Pulling all these lines together, Line 12g (total eligibles who received any service) reflects all eligibles who received either an oral service or a dental service. When reporting the number of eligibles for 12g, a good validation tip for accuracy would be to make sure that Line 12g is the unduplicated sum of line 12a (any dental service) and line 12f (oral health services). Please note that 12d is missing from the graphic. That’s because eligibles counted in 12d might fall into either 12b or 12f depending on what type of provider applied the sealant. On the next slide, we will review more information about how to include eligibles who got a sealant on Lines 12f and 12g. Now let’s return to line 12d (sealants). In addition to being counted in Line 12d, eligibles who received a sealant on a permanent molar will also be counted on one or more other lines, depending on the type of provider who delivered the service. Looking at the graphic, we see that, if a child received a sealant from or under the supervision of a dentist, in addition to being counted on Line 12d that child will be counted in Line 12b as having received a preventive dental service and in Line 12a as having received any dental service. On the other hand, if the sealant is applied by a non-dentist provider not under the supervision of a dentist, in addition to being counted on Line 12d the child will also be counted on Line 12f as an oral health service. As a reminder, line 12g represents an unduplicated total of individuals counted in Lines 12a through 12f. So even though on Line 12g you aggregate all the individuals who received any type of dental service or an oral health service, you will need to deduplicate Line 12g so that any individual child appears only once in that Line no matter how many dental and oral health services the child may have received. Let’s talk a bit more about the difference between Dental and Oral Health Services. For the purposes of Form CMS-416 reporting, dental services are services provided by or under the supervision of a dentist. Supervision is a spectrum and includes, for example, direct, indirect, general, collaborative, and public health supervision as provided for in the state’s dental practice act. In contrast, oral health services are services provided by a non-dentist provider. A “non-dentist provider” is any qualified health care practitioner who is neither a dentist nor providing services under the supervision of a dentist. For example, some states allow non-dentist providers such as physicians to apply fluoride varnish. And some states allow dental hygienists or other dental practitioners to provide services without any type of supervision by a dentist. States have different policies about how oral health services are billed to Medicaid, so check with your agency about how best to identify and report these data. Let’s talk more about line 12f. Line 12f is the unduplicated count of all eligibles that receive any Oral Health Service. And as we just learned oral health services are those that are delivered by a non-dentist, such as a physician, or by a dental practitioner not under the supervision of a dentist. These would typically be oral evaluations or assessments, as well as fluoride applications and other types of preventive services. As you see in the graphic below, remember that children who receive sealants on permanent molars (from line 12d) are also to be included in the count for Line 12f, but only if the sealant was placed by a non-dentist not under the supervision of a dentist. Now, let’s review why Lines 12f and 12g are important. Lines 12f – oral health services — and 12g – any dental or oral health service — are important because they help provide insight into your state’s level of dental and oral health service utilization as well as the extent of involvement in your state of medical providers in ensuring children’s oral health. Line 12f reflects the role that non-dentist providers play in meeting the need for preventive oral health services to children in your state. When compared to Line 1b (the number of eligibles with at least 90 days of continuous enrollment), Line 12g can help you determine whether there is unmet need for dental or oral health services in your Medicaid population. Now that we’ve covered the types of services included on each line, let’s talk about reporting by age ranges. All data reported on the Form CMS-416 must be stratified by age. There are seven separate age ranges on the form. These are: less than 1 year, 1 to 2 years, 3 to 5 years, 6 to 9 years, 10 to 14 years, 15 to 18 years, and 19 to 20 years. Understanding these age ranges is important because: There are different age ranges for which delivery of specific EPSDT services are appropriate. For example, the Form CMS-416 only collects data on the application of sealants to permanent molars for children in two of the age categories: 6 through 9 and 10 through 14. Stratifying your data can also help identify any gaps in access or areas for improvement. When reporting in lines 12f and 12g, it is important to accurately determine which age range is appropriate for each child or service you are reporting. You should report all data – including eligibility, services and screenings – in the age group reflecting the individual’s age as of September 30th of the reporting year. This means that all data relevant to an individual child should only be reported in the same age category across the entire Form CMS-416. The federal fiscal year is from October 1st through September 30th. For example, federal fiscal year 2015 is October 1st, 2014 through September 30th, 2015. Let’s review an example of how to determine which age range to use when reporting an individual child’s data. Remember, a child should be counted in the age group reflecting the child’s age as of September 30th of the reporting year. For our example, we’ll assume we are reporting for federal fiscal year 2015. Let’s say a child was born on January 12, 2012 and he received an oral health service on April 30, 2015. This child would turn 3 years old on January 12th, 2015, so he would still be 3 years old on September 30, 2015. Since he’d be 3 years old on September 30th, 2015 (the end of the federal fiscal year), we would include him in the 3 to 5 year age group on Line 12f. Now it’s time for a pop quiz! Let’s take a moment and see if we can determine which age range is appropriate in the example below. Nicole was born August 4th, 2012. At her 30-month well-child visit (which took place on February 4th, 2015), her primary care physician applied fluoride varnish to her teeth and billed it using CDT code D1206. This was an oral health service because it was provided by a non-dentist. Which age category should Nicole be included in for reporting on Line 12f on the federal fiscal year 2015? Is the answer A: 1 to 2 years; answer B: 3 to 5 years; answer C: Both A and B; or answer D: Neither A or B. Take a moment and think about your answer to this question. Remember, the right age group for Nicole is where she falls as of September 30th of the reporting year, which is not necessarily the age she was on the date of service. What is Nicole’s age on September 30th, 2015? If you answered B: 3 to 5 years, you’d be correct! Great job! 3 to 5 is the correct age group because Nicole would turn 3 years old on August 4th 2015, and would still be 3 years old at the end of the federal fiscal year, on September 30th 2015. Some people may be confused by the fact that Nicole was 2 years old when she received the service, but because she was 3 years old on September 30th of the reporting year, she should be included in the 3 to 5 age group. Now, let’s review coding guidance for oral health services. In order to identify oral health services, you’ll need to be able to identify services provided by non-dentist providers or services provided not under the supervision of a dentist. Some states maintain a taxonomy of providers, which can contain data on the types of providers who are permitted to bill Medicaid and the types of services they are permitted to bill for. Contact your state’s Medicaid database administrator to see if this resource is available. States may also divide access to their dental and medical claims systems according to provider type. If this is the way your state has structured its claims processing, non-dentist providers may only be able to submit claims through the medical claims system. In this situation, non-dentist providers can be easily identified by exclusively using medical claims. In addition, you will need to be familiar with your state’s dental practice act to know which, if any, services may be provided by a dental professional without any supervision from a dentist. If there are any such services in your state, you will need to determine how to discern from your claims which services those were so they can be reported accurately as oral health services rather than dental services. You can find additional resources for Form CMS-416 Reporting on the EPSDT page and the Learn How to Report the CMS 416 Dental Data page at Medicaid.gov. These resources include: Form CMS-416 Instructions A Frequently Asked Questions document CPT-CDT Crosswalk The Form CMS-416 Links to the EPSDT Technical Assistance (or TA) Mailbox to submit EPSDT-related questions A worksheet of Common Definitions And the Form CMS-416 Web-Based Training Homepage Now let’s talk about some commonly used coding systems. Dentists bill using the Code on Dental Procedures and Nomenclature, also known as the CDT code set. Non-dentist providers use Healthcare Common Procedure Coding System (or HCPCS) codes and Current Procedural Terminology (or CPT) codes more frequently than CDT codes when billing for services. However, many states require medical providers to bill for oral health services using CDT codes. CMS has developed a crosswalk of service codes between CPT, CDT, and HCPCS to assist states in reporting dental and oral health data on the Form CMS-416. The table on this slide displays part of the crosswalk of services codes. Here, we see that the parallel CPT code for CDT code D1310 (nutritional counseling for control of dental disease) is 96152. It is important to note that this crosswalk is not comprehensive. Therefore, it can be helpful to review it with content experts in your state (such as a primary care provider organization) for their perspective on its accuracy and relevance to the way dental and oral health procedures are billed in your state. To review the crosswalk of service codes, please visit the EPSDT page at Medicaid.gov. Let’s continue our discussion of Oral Health Services. There are several other considerations in identifying oral health services. For example, the American Medical Association recently adopted a new CPT code: 99188 (for topical application of fluoride varnish by a physician), which is similar to CDT D1206 (for topical application of fluoride varnish). The code used to bill for a service can help you determine whether the service should be categorized as an oral health service or a dental service. For example, a claim using CPT 99188 for fluoride varnish will almost always be from a medical provider, and thus would be categorized as an oral health service. But a claim using CDT D1206 is not definitive because most states allow both medical and dental providers to bill for fluoride treatments using this code. Your state’s dental practice act may also be relevant in determining whether a service should be categorized as an oral health service or a dental service. For example, some state practice acts allow dental hygienists to perform certain services without any dental supervision in some types of settings (such as in schools). Those should be categorized as oral health services. If you can accurately identify services administered by these providers in those settings, include eligibles who received these services in Line 12f of the Form CMS-416. There is one more dimension to reporting oral health services on the Form CMS-416. Children often receive an oral health service, such as fluoride varnish, in the context of an overall well-child visit. The question arises: under what circumstances should you count such a child on both the well-child visit line of the Form CMS-416 (Line 9 – total eligibles receiving at least one initial or periodic screen) and on the oral health services line (Line 12f)? When an oral health screening or other oral health service is coded and reimbursed separately from the overall well-child visit, you should include the child on both Lines, as shown in the image to the right. When an oral health screening or other oral health service is included in the code and payment for the well-child check-up, you should only include the child on Line 9, and not on Line 12f. So, how do we ensure data quality? There are four main components of data quality. These are completeness, consistency, accuracy, and documentation. Performing checks for each of the components of data quality will help ensure that your Form CMS-416 submission will meet the program requirements. Completeness refers to the extent to which your dataset contains all the information needed. In reporting Form CMS-416 dental data, typical completeness checks include whether you’ve captured data from the full member population, all provider types, all delivery systems, all plans, all payment methodologies, and all services. Consistency refers to whether you apply consistent logic in assembling and calculating your information. In reporting Form CMS-416 data, consistency often comes into play when pulling claims that match the population that you are trying to represent. For example, if you run a query that identifies the pool of eligible Medicaid enrollees, it makes sense to run future queries calculating the services delivered using the same program that generated that initial pool of eligibles. Accuracy refers to how close your data are to representing reality. In reporting Form CMS-416 data, accuracy checks typically involve referencing other data or reports to help identify unexplained variation. Documentation is how you explain the process for your data calculations, structure of your data, and any manipulations you applied. In reporting Form CMS-416 data, documentation is critical to ensuring that your data can be understood, interpreted, and reproduced by any user. In the next slides, we will walk through each component of the data quality review for Lines 12f and 12g. We will discuss what each check can include and how they can enhance the quality of your Form CMS-416 data. Next, we are going to walk through each of the four components of data quality. For each component, we will consider a short set of questions you should ask yourself about your data and your data collection. All together, these four sets of questions make up a data quality approach that we will recommend you carry out each year before submitting your form CMS-416 data to CMS. We’ll start by performing a check of data completeness. Here’s the first question: Do your data include unduplicated paid, pending, and denied claims? If you answered No, remember that new in 2014, CMS asks that pending and denied claims be included along with paid claims in reporting services provided to eligibles. Reference the instructions and FAQs on the EPSDT page at Medicaid.gov for additional assistance if necessary. If you answered Yes, Great job! Let’s move to the next step. Here’s the second question: Have you checked your data for duplicates to make sure you are not double-counting individuals within each Line? If you answered No, keep in mind that de-duplicating your pool of eligibles is a critical data quality check. Try running a query to identify potential duplicates, using fields such as member ID number, date of birth, or social security number. Remember, report each line separately taking into consideration that lines are all subsets of 1b. If you answered Yes, great job! One technique is to run a query to identify potential duplicates, using fields such as member ID number, date of birth, or social security number. Let’s move to the next step. Here’s the third data completeness question: Do the data you have represent the entire Medicaid and CHIP population that is eligible for the EPSDT benefit? Remember, children enrolled in separate CHIP programs should not be included in your reporting for Form CMS-416. This is true even if you provide the equivalent of the EPSDT benefit to children in your separate CHIP. And finally, have you included all relevant providers, plans, services, and alternative payment methods? If you answered No, remember that before submitting your data, check with your database administrator to make sure you can access the necessary data. One frequent gap in state reporting is dental services provided at Federally Qualified Health Centers. Some states do not receive detailed dental claims for these visits and are thus unable to fully report these services on the Form CMS-416. At the very least, make sure to document which populations, providers, settings, or services are missing from your calculations when you submit the Form CMS-416. If you answered Yes, great job! Keep in mind that no dataset is perfect – make sure to document which populations are missing from your calculations when you submit the Form CMS-416. Let’s move to the next step. The second data quality check looks at data consistency. Ask yourself, for the reporting on Lines 12f and 12g, did you start with the same pool of eligibles included in Line 1b (the number of eligibles with at least 90 days of continuous enrollment)? If you answered No, remember that all individuals included in Lines 12f and 12g are a subset of Line 1b. You should start with the same datasets when you calculate these fields in order to make sure the internal logic being used is consistent. If you answered Yes, great job! Let’s move to the next step. Next, have you accounted for the relationship between Lines 12g, 12f, and 12a? If you answered No, remember that Line 12g is an unduplicated count of children receiving any dental or oral health services. If a child has a dental service, they should be counted on Line 12a, as well as Line 12g. If a child has an oral health service, the child should be counted on Line 12f as well as Line 12g. If one child has both an oral health service (in Line 12f) and a dental health service (in Line 12a), that child should only get counted once on Line 12g. If you answered Yes, great job! It can be tricky to appropriately categorize and deduplicate eligibles who receive oral and dental health services. Be mindful of the relationship between these Lines when reporting data to CMS. Let’s move to the next step. A good practice is to compare this year’s results to previous years’, Line by Line. Speaking specifically of Lines 12f and 12g, if there are any differences that strike you as unusual or unexpected, can you explain those differences? If you answered No, keep in mind that comparing your data to what you reported in previous years can help you spot errors in your results. Some variation might be reasonable – for example, if your agency recently expanded the scope of dental practice to a large number of new providers, you might see a large increase in services from one year to the next. However, if you can’t identify a reasonable explanation, consider double-checking your code. If you answered Yes, great job! Comparing your data to what you reported in previous years can help you spot errors in your results. Let’s move to the next step. And finally, did you conduct a code review? If you answered No, remember that code reviews are a great way to check that the programming logic being used is consistent with the requirements of the field. Consider conducting a code review that partners the original programmer, a senior programmer for a fresh set of eyes, and the policy manager engaged in Form CMS-416 reporting in order to validate the calculations. If you answered Yes, great job! Code reviews are a great way to check that the programming logic being used is consistent with the requirements of the field. Let’s move to the next step. The third data quality component is accuracy. There are three steps to this check. Remember that for Lines 12f and 12g, it is important to distinguish the type of provider who delivered the service. Ask yourself whether your logic has been consistent regarding how you categorize services provided by dentists and under the supervision of a dentist versus non-dental providers? If you answered No, keep in mind that using inconsistent logic can lead to inaccuracies in your reported data. Make sure you use the same internal rules in categorizing provider types throughout your calculations for Lines 12f and 12g of the Form CMS-416. If you answered Yes, great job! It is important to use the same internal rules in categorizing provider types throughout your calculations for Lines 12f and 12g of the Form CMS-416. Let’s move to the next step. Next, did you count children who received oral health services during well-child visits when the oral health service was reimbursed separately from the well-child visit? If you answered No, remember that oral health services provided during wellness visits can be counted on Lines 12f and 12g if they are paid separately. Review the coding guidance from this module for details on which procedure codes could reflect oral health services in medical claims. If you answered Yes, great job! Remember to review the coding guidance from this module for details on which procedure codes could reflect oral health services in medical claims. Let’s move to the next step. Finally, do the codes for services you counted line up with the ones listed in the crosswalk? As a reminder, CMS has developed a crosswalk of service codes between CPT, CDT, and HCPCS to assist states in reporting dental and oral health data on the Form CMS-416. If you answered No, remember that if you see services in your reporting that don’t match the list of codes provided in CMS’s crosswalk, consider touching base with a billing expert to make sure the services should be included. To review the crosswalk and other resources, please visit the EPSDT page at Medicaid.gov. If you answered Yes, great job! But remember, the crosswalk is not comprehensive. Therefore, it can be helpful to review it with content experts in your state (for example, a primary care provider organization) for their perspective on its accuracy and relevance to the way dental procedures are billed in your state. Let’s move to the next step. The last component of data quality review looks at documentation. Here we have two questions. When you review the data ask yourself whether you have kept a written record of the code and specifications for your inputs, programs, outputs, and other instructions for future reference. If you answered No, keep in mind that since reporting the Form CMS-416 is an annual requirement, good documentation will help to ensure year-over-year consistency, as well as provide helpful guidance if there are questions about how your results were derived. If you answered Yes, great job! Let’s move to the next step. Here’s the second question on documentation: Have all program changes and data limitations been described in the cover correspondence? If you answered No, remember that providing this information in the cover correspondence you send to CMS with your Form CMS-416 is essential to CMS’s efforts to monitor performance on goals over time. If there are any issues that impact your data (such as data from a particular MCO are unavailable, or that your state migrated to a different eligibility system mid-year), make sure to describe these issues when you submit the Form CMS-416. If you answered Yes, great job! If there are any issues that impact your data, make sure to describe these issues when you submit the Form CMS-416. Let’s review the Module 5 summary. In this module,… You learned that Line 12f counts children who received an oral health service delivered by a non-dentist provider. You also learned that Line 12g is the unduplicated total of eligibles included in Line 12f (for oral health services) and Line 12a (for dental services). You learned what differentiates an oral health service from a dental service. And finally, you learned how to determine the age group in which to report a child’s data based on the age of the child at the end of the reporting period. Congratulations! You have completed Module 5: Form CMS-416 Specifications – Lines 12f and 12g. To access Module 6, other training modules, and relevant Form CMS-416 resources, please visit the CMS Web-Based Training homepage at Medicaid.gov. For questions about the Form CMS-416 or the Oral Health Initiative, access the complete Form CMS-416 reporting instructions on the EPSDT page at Medicaid.gov, or email the EPSDT Technical Assistance Mailbox at [email protected]

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