For Medicaid-Enrolled Children Diagnosed With Lead Toxicity in Five States, Documentation Reviewed for Diagnoses and Treatment Services Raises Concerns

KEY TAKEAWAY

In five States, most of the medical records that our study reviewed for children with a lead toxicity diagnosis in their Medicaid claims lacked adequate information to confirm a diagnosis of lead toxicity, highlighting potential concerns for oversight of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Among children for whom there was sufficient medical record documentation to confirm their diagnosis, many did not receive comprehensive followup testing and treatment services, as recommended, for their identified blood lead level.

WHY WE DID THIS STUDY

Lead toxicity is an environmental health concern that can have lasting effects on the lives of children. Although there is no safe level of lead exposure for young children, exposure is preventable. Children's exposure to lead can be minimized through actions such as regular cleaning of the home; washing of hands and toys; and preventive care to support early detection of lead toxicity and timely followup testing and treatment services.

An Office of Inspector General (OIG) found that more than one-third of Medicaid-enrolled children in five States (California, New York, Ohio, Pennsylvania, and Texas) did not receive required blood lead screening tests during fiscal years (FYs) 2015-2018, which potentially left children vulnerable to the toxic effects of lead exposure. This study expands on that work.

The Centers for Medicare & Medicaid Services' (CMS's) Medicaid program offers comprehensive preventive medical screening services for millions of children annually through the EPSDT benefit. This benefit also includes treatment services to correct issues (e.g., lead toxicity) identified through screenings, such as blood lead testing. When young children with confirmed blood lead levels do not receive timely followup testing and treatment services, they could be left vulnerable to continuing lead exposure and permanent developmental effects.

HOW WE DID THIS STUDY

For the same five States, we reviewed Medicaid claims data for FYs 2015-2018. From this data, we selected a sample of 625 enrolled children with a diagnosis indicating lead toxicity, and reviewed children's medical records from the date of diagnosis through 6 months later. The review examined whether children received followup testing and treatment services for their identified blood lead levels (FYs 2015-2019), as recommended by CMS and the Centers for Disease Control and Prevention (CDC). We also collected public health data from four States to account for services provided exclusive of Medicaid payment and received outside clinical settings, and we asked medical reviewers to consider the respective State medical management guidance. Finally, we interviewed stakeholders regarding followup testing and treatment services for children exposed to lead.

WHAT WE FOUND

In this evaluation of medical records for Medicaid-enrolled children with a diagnosis of lead toxicity in Medicaid claims, medical reviewers could not identify adequate information to confirm that diagnosis in the majority of records (415 out of 581 children).

It is unclear why this many medical records, across five States, lacked information to confirm the diagnosis of lead toxicity identified in the Medicaid claims. According to the American Academy of Pediatrics, it could be a matter of confusion about appropriate diagnosis codes. Nonetheless, the lack of documentation in the medical records to confirm children's lead toxicity diagnoses raises concerns regarding the accuracy of using Medicaid claims data, solely, to identify children being treated for lead toxicity. It may also have implications for States' annual EPSDT reporting to CMS regarding treatment services.

Because there is no safe lead level for children, even very low blood lead levels may indicate in some instances a need for treatment, based on individual factors (e.g., age, environment, increasing blood lead level trend). However, without adequate information in the medical record of a blood lead level at or above 5 'g/dL, or signs, symptoms, and/or notes regarding an elevated blood lead level, medical reviewers could not objectively distinguish children whose medical records indicated a need for followup testing and treatment services during the 6-month review period. Similarly, without accurate data, CMS may be unable to accurately measure EPSDT performance and ensure that Medicaid enrolled children with lead toxicity are given the best possible health care.

For this review, medical reviewers determined appropriate services for lead toxicity using their professional judgment, with reference to followup testing and treatment services recommended by CMS and CDC, and in consideration of State medical management guidance for children's identified blood lead levels. Among the 166 children with sufficient medical record documentation to confirm their diagnoses, medical reviewers determined that half of the children did not receive comprehensive followup testing and treatment services (e.g., environmental assessments to determine the source of exposure) as recommended.

WHAT WE RECOMMEND

We recommend that—to address concerns related to the accuracy of claims data for Medicaid enrolled children diagnosed with lead toxicity, and related to the treatment component of EPSDT for these children—CMS (1) explore the discrepancy between Medicaid claims data and medical documentation for lead toxicity and implement solutions to ensure better oversight of the EPSDT program; and (2) issue guidance to reiterate State obligations under the EPSDT benefit to ensure access to services to correct or ameliorate confirmed blood lead levels identified during screenings. CMS concurred with both of the recommendations.