TennCare Preventive Services Coverage

What CPT codes fall under TennCare’s EPSDT requirement?
All TennCare MCOs are required to process certain CPT codes as “covered services” under the Preventive Services aegis.    Some of them are related to OB/GYN services.  Here are some of the ones of interest to pediatricians:
New patient well visits:
  • 99381 – Initial evaluation
  • 99382 – ages 1 through 4 years
  • 99383 – ages 5 through 11 years
  • 99384 – ages 12 through 17 years
  • 99385 – ages 18 through 39 years

Established patient well visits:

  • 99391 – Periodic evaluation
  • 99392 – ages 1 through 4 years
  • 99393 – ages 5 through 11 years
  • 99394 – ages 12 through 17 years
  • 99395 – ages 18 through 39 years

Individual counseling and risk factor reduction intervention:

  • 99401 – approximately 15 minutes
  • 99402 – approximately 30 minutes
  • 99403 – approximately 45 minutes
  • 99404 – approximately 60 minutes

Group counseling and risk factor reduction intervention:

  • 99411 – approximately 30 minutes
  • 99412 – approximately 60 minutes

Other Preventive Services:

  • 99173 – Vision
  • 96110 – Developmental Code – Limited
  • 99420 – Administration and interpretation of health risk assessment instrument (e.g., health hazard appraisal)
  • 99431 – Newborn – Initial Hospitalization
  • 99435 – Newborn – Assessment and Discharge Same Day
  • 90700 through 90744 – Immunizations
  • 92551 – Screening test, pure tone, air only (Audiologic function)
  • 92552 – Pure tone audiometry (threshold); air only

TennCare MCOs should always classify these  CPT codes as covered services, based on TennCare Rule 1200-13-13-.04.  Claims including these CPT codes may be properly denied for other reasons (lack of coverage, timely filing, etc), of course.

Other codes not in this list are always covered services (99213) by all MCOs, but these are the ones that are considered “preventive services” and thus fall under other preventive services rules (like pay and chase.)

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