Clinical Guidelines

To help provide our members with consistent, high-quality care that utilizes services and resources effectively, we have chosen certain clinical guidelines to help our providers. These are treatment protocols for specific conditions as well as preventive health guidelines.

These guidelines are intended to clarify standards and expectations. They should not:

  • Come before your responsibility to provide treatment based on the member’s individual needs.
  • Substitute as orders for treatment of a member.
  • Guarantee coverage or payment for the type or level of care proposed or provided.

We have adopted these evidence-based guidelines.

To learn more about the guidelines and to access helpful tool kits on treating various behavioral disorders, follow the links below:

Arizona Opioid Prescribing Guidelines

If you are a pediatrician or family medicine practitioner working with children, make sure you fully understand the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program and are familiar with the Childhood Immunization Schedule.

  • EPSDT Program: To help ensure children under age 18 get the screenings and preventive care they need, please refer to the EPSDT Periodicity Schedule.

Childhood Immunization Schedule

Well Visit Codes for EPSDT Members

 

Well-Visit Ages New Patients

CPT Codes

ICD-10 Codes

  

Well-Visit Ages Established Patients

CPT Codes

ICD-10 Codes

Infant (Younger than 1 Year)

99381

Z00.110 Z00.111 Z00.121 Z00129

  

Infant (Younger than 1 Year)

99391

Z00.110 Z00.111 Z00.121 Z00.129

1-4 Years

99382

Z00.121 Z00.129

  

1-4 Years

99392

Z00.121 Z00.129

5-11 Years

99383

Z00.121 Z00.129

  

5-11 Years

99393

Z00.121 Z00.129

12-17 Years

99384

Z00.121 Z00.129

  

12-17 Years

99394

Z00.121 Z00.129

18 Years or Older

99385

Z00.00 Z00.01

  

18 Years or Older

99395

Z00.00 Z00.01

 

As patients age, it remains important that we catch diseases as early as possible to be able to provide the best care that can lead to the best possible outcomes. Learn more about preventive and treatment guidelines for specific conditions in adults.

  • Adult immunization schedule: Don’t forget – kids aren’t the only ones who need immunizations. Make sure adult members are up-to-date on their influenza, Hepatitis A and B, MMR and other vaccines.
  • Community-Acquired Pneumonia (CAP) Clinical: The CAP Clinical Guidelines is to develop an integrated approach to the outpatient management of CAP with an emphasis on prevention, early detection and patient education. View guidelines from the Infectious Diseases Society of America website and American Thoracic Society Consensus.
  • HIV guidelines: Mercy Care advises providers to refer to the guidelines and resources provided by the National Institutes of Health on its website.
  • Preventive health care guidelines for adults:

Test

  • 18-25
  • 26-39
  • 40-49
  • 50-65
  • 65 and older

(health maintenance exam by age)

 

Pap tests (cervical cancer screening)

Diabetes screening

Frequency

 Every 5 years

 Every 5 years

 Every 3 years

 Every 1-2 years

 Every 1-2 years

Every one to three (1-3) years starting at age 18 or when sexually active. Frequency may decrease when there is no history of abnormal Pap tests and three or more tests are normal.

Test at age 45 for adults with no symptoms and then every three (3) years.

If you are treating children with behavioral health disorders, Mercy Care offers a variety of resources related to anxiety, depression and ADHD. Click on the links below to download PDFs of these resources and tools.

Anxiety

Depression

Attention Deficit/Hyperactivity Disorder (ADHD)

The follow resources are intended to help behavioral health providers diagnose and treat behavior health disorders in adults. Click on the links below to download PDFs of the tool kits.