Section. CPT only copyright 2005 American Medical Association. All rights reserved. 43Texas Health Steps (THSteps)

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1 Section 43Texas Health Steps (THSteps) THSteps Medical and Dental Administrative Information Overview Statutory Requirements Medical Transportation Program Provider Enrollment Additional Education Requirements for Registered Nurses (RNs) Medicaid Managed Care Enrollment Eligibility for a Medical Checkup Newborn Eligibility Reimbursement Medical Checkup Newborn Examination Medical Checkup, First 6 Days of Life Exceptions to Periodicity Follow-up Medical Checkup Visit Verification of Medical Checkups Claims Information Procedure Coding for THSteps Medical Checkups Immunizations Billed Within THSteps Medical Checkups, Exception to Periodicity, and Follow-Up Visit Immunizations Billed Outside of THSteps Medical Checkups, Exception to Periodicity, or Follow-Up Visit Billing Claim Filing Resources THSteps Medical Checkup Facilities Medical Home Concept Continuity of Care and the Medical Home Mobile Units and the Medical Home THSteps Dental Services How the THSteps Dental Program Works Vision Services Hearing Services Referrals for Medicaid-Covered Services Texas Vaccines for Children Program Benefits and Limitations Information and Assistance Assistance with Program Concerns Assistance with Claims Concerns Clinical Information Documentation of Completed Checkups THSteps Medical Checkups Periodicity Schedule THSteps Medical Checkups Periodicity Schedule for Infants, Children, and Adolescents (Birth Through 20 Years of Age) THSteps Medical Checkups Periodicity Schedule for Infants and Children (Birth Through 20 Years of Age) (continued) Medical Checkups for Infants, Children, and Adolescents (Birth Through 20 Years of Age) CPT only copyright 2005 American Medical Association. All rights reserved.

2 Section History Physical Measurements Nutritional Assessment Developmental Assessment Mental Health Sensory Screening Tuberculosis Screening Immunizations Dental Assessment Medical Checkup Laboratory Component Health Education/Anticipatory Guidance Additional Adolescent Screening Checkup Laboratory Procedures Laboratory Services Laboratory Supplies Required Tests Glucose Hemoglobin or Hematocrit Hemoglobin Type Hyperlipidemia Lead Screening Newborn Screening Urinalysis Follow-Up Care Guidelines Summary Table Additional Required Laboratory Tests Related to Medical Checkups for Adolescents Communicable Disease Reporting Cervical Cancer Screening STD Testing THSteps-Comprehensive Care Program (CCP) THSteps-CCP Overview Enrollment Medicaid Managed Care Enrollment Communication with THSteps-CCP Client Eligibility Benefits Prior Authorization and Documentation Requirements Physician Signature Comprehensive Outpatient Rehabilitation Facilities (CORFs)/Outpatient Rehabilitation Facilities (ORFs) Enrollment Reimbursement Benefits and Limitations Claims Information Durable Medical Equipment Supplier (THSteps-CCP Only) Enrollment Reimbursement Benefits and Limitations Physician Signature Mobility Aids Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers, Standing Frames/Braces, and Parapodiums) CPT only copyright 2005 American Medical Association. All rights reserved.

3 Texas Health Steps (THSteps) Apnea Monitor Croup Tent/Pulse Oximeter Electronic Blood Pressure Monitoring Device Incontinence Supplies for Children Younger Than 4 Years of Age Pediatric Hospital Cribs/Enclosed Beds/Reflux Wedges and Slings Medical Nutritional Products Donor Human Milk Special Needs Car Seats and Travel Restraints Early Childhood Intervention (ECI) (THSteps-CCP Only) Enrollment Reimbursement ECI-CCP Services Claims Information Licensed Dietitians (THSteps-CCP Only) Enrollment Reimbursement Benefits and Limitations Claims Information Occupational Therapists (THSteps-CCP Only) Enrollment Reimbursement Benefits and Limitations Claims Information Orthotic and Prosthetic Suppliers (THSteps-CCP Only) Enrollment Reimbursement Benefits and Limitations Cranial Molding Devices Corrective Shoe, Wedge, and Lift Claims Information Pharmacies (THSteps-CCP Only) Enrollment Reimbursement Eligibility Benefits and Limitations Claims Information Physical Therapists (THSteps-CCP Only) Enrollment Reimbursement Benefits and Limitations Claims Information Private Duty Nursing (PDN) THSteps-CCP Only Enrollment Reimbursement Criteria Authorization Documentation Psychiatric Hospital/Facility (Freestanding) (THSteps-CCP Only) Enrollment Reimbursement LoneSTAR Select 015 Managed Care Benefits and Limitations CPT only copyright 2005 American Medical Association. All rights reserved. 43 3

4 Section Claims Information Rehabilitation Hospital (Freestanding) (THSteps-CCP Only) Enrollment Continuity of Hospital Eligibility Through Change of Ownership Reimbursement Benefits and Limitations Claims Information Speech-Language Pathologists (THSteps-CCP Only) Enrollment Reimbursement Benefits and Limitations Prior Authorization, Documentation Requirements Claims Information THSteps-CCP Claim Filing Resources CPT only copyright 2005 American Medical Association. All rights reserved.

5 Texas Health Steps (THSteps) 43.1 THSteps Medical and Dental Administrative Information This section describes the administrative requirements for the Texas Health Steps (THSteps) Program, including provider requirements, client eligibility requirements, and billing and claims processing information. "Clinical Information" on page contains information for medical and dental services provided under THSteps. Providers needing additional information, may call or refer to the THSteps Quick Reference Guide on page M-1 for a more specific list of resources and telephone numbers. Providers may also contact the DSHS THSteps Provider Relations staff in the DSHS regional office by calling the appropriate regional office as listed in DSHS Health Service Region Contacts on page A Overview The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service is Medicaid s comprehensive preventive child health service for individuals younger than 21 years of age. In Texas EPSDT is known as the THSteps program. EPSDT was defined by federal law as part of the Omnibus Budget Reconciliation Act (OBRA) of 1989 legislation and includes periodic screening, vision, hearing, and dental preventive and treatment services. In addition, Section 1905(r)(5) of the Social Security Act requires that any medically necessary health care service listed in the Act be provided to THSteps (EPSDT) clients even if the service is not available under the State s Medicaid plan to the rest of the Medicaid population. These additional services are available through the Comprehensive Care Program (CCP). THSteps-CCP services are the diagnosis and treatment components of THSteps Statutory Requirements Several specific legislative requirements affect the THSteps program and the providers participating in the program. These include, but are not limited to, the following: Newborn Blood Screening, Health and Safety Code, Chapter 33. Parental Accompaniment, as outlined in Appendix K, THSteps Statutory Requirements, Parental Accompaniment on page K-2. Requirements for Reporting Abuse or Neglect, as outlined in "Compliance with Texas Family Code" on page 1-4. Simplified Enrollment, Texas Human Resources Code, Early Childhood Intervention (ECI), 34 Code of Federal Regulations (CFR) Part 303; Chapter 73, Texas Human Resources Code, and Title 40 Texas Administrative Code (TAC), Chapter 108. Newborn Hearing Screening, Health and Safety Code, Chapter 47. Teen Confidentiality Issues. There are many state statutes that may affect consent to medical care for a minor, depending on the facts of the situation. Among the relevant statutes are Chapters 32, 33, 153, and 266 of the Texas Family Code. Providers may want to consult an attorney, their licensing board, or professional organization if guidance is needed or questions arise on matters of medical consent. Refer to: Texas Health Steps Statutory State Requirements on page K-1 for more information Medical Transportation Program On request by the client, the Texas Department of Transportation Medical Transportation Program (MTP) can assist the client with scheduling transportation for THSteps medical and dental checkups. Refer to: Medical Transportation on page I-1 for more information Provider Enrollment Providers cannot be enrolled if their professional license is due to expire within 30 days of application. Facility providers must submit a current copy of the supervising practitioner's license. To enroll in the THSteps program, providers must be enrolled in the Texas Medicaid Program, in addition to one of the following: Physicians (doctor of medicine [MD] and doctor of osteopathy [DO]) currently licensed in the state where the service is provided. Health care providers or facilities (public or private) capable of performing the required medical checkup procedures under a physician s direction, such as regional and local health departments, family planning clinics, migrant health clinics, community-based hospitals and clinics, maternity clinics (MSCs), rural health clinics (RHCs), federally qualified health centers (FQHCs), home health agencies (HHAs), school districts, and family or pediatric nurse practitioners. In the case of a clinic, a physician is not required to be present in the clinic at all times during the hours of operation; however, a physician must assume responsibility for the clinic s operation. Family and pediatric nurse practitioners enrolled independently. Certified nurse-midwives (CNM) enrolled as providers of THSteps medical checkups for newborns younger than 2 months of age and adolescent females. Women s health care nurse practitioners enrolled as providers of THSteps medical checkups for adolescent females. Adult nurse practitioners (ANP) enrolled as providers of THSteps checkups for adolescents. 43 CPT only copyright 2005 American Medical Association. All rights reserved. 43 5

6 Section 43 Effective July 1, 2006, physician assistants (PAs) may enroll independently as THSteps medical providers. It is recommended that PAs have expertise or additional education in the areas of comprehensive pediatric assessment. Residents may provide medical checkups in a teaching facility under the personal guidance of the attending staff as long as the facility s medical staff by-laws and requirements of the Graduate Medical Education (GME) Program are met, and the attending physician has determined the intern or resident to be competent in performing these functions. THSteps does not require the supervising physician to examine the patient as long as these conditions are met. A registered nurse (RN) may not enroll independently, but may perform THSteps medical checkups only under the supervision of a physician. The physician ensures that the RN or PA has appropriate training and adequate skills for performing the procedures for which they are responsible. Refer to: "Provider Enrollment" on page 1-2 for information about enrollment procedures Additional Education Requirements for Registered Nurses (RNs) All RNs performing THSteps medical checkups must receive special training in comprehensive pediatric assessment. To be qualified to conduct a THSteps physical examination, RNs must have completed courses in pediatric assessment after graduation from nursing school, which includes the following components: physical, developmental/mental health, nutrition assessment, and anticipatory guidance. This education may be obtained through credit hours at an accredited college or university or through courses approved for continuing education units. If the pediatric course(s) do not include a formal preceptorship (observation by course faculty or their designee of the individual s skills over a period of time), the RN should receive personal supervision by a physician (or family or pediatric nurse practitioner) until the physician (or family or pediatric nurse practitioner) determines the RN to be competent to perform these functions. Documentation of the required special training should be included in the employee s personnel file. It is recommended that PAs have expertise or additional education in the areas of comprehensive pediatric assessment. Courses offered by the Texas Nurses Association (TNA) are available for PAs and provide continuing education units for PAs and RNs. The courses are: Comprehensive Pediatric Assessment. The curriculum includes an overview of THSteps family medical history, pediatric physical assessment, nutrition, developmental and mental health assessments, case management, and anticipatory guidance. A clinical preceptorship with a physician or advanced practice nurse (APN) is part of this training. Adolescence (web-based). This course gives health care providers (including PAs, nurse practitioners (NPs), clinical nurse specialists (CNSs), RNs, social workers, nutritionists, and dietitians) information that can assist them in relating to and providing care for adolescents. Texas Health Steps Adolescent Checkup (web-based). This course provides the RN with recommended guidelines and necessary forms for conducting a THSteps adolescent checkup. For more information, nurses can contact TNA at or by telephone at , or call THSteps at Refer to: "Provider Enrollment" on page 43-5 for more information about enrollment procedures Medicaid Managed Care Enrollment The Medicaid Managed Care Program consists of two types of health care delivery systems, Primary Care Case Management (PCCM) and health maintenance organization (HMO). THSteps medical providers do not have to enroll with PCCM to be reimbursed for medical checkup services provided to PCCM clients. Bills are submitted directly to TMHP, and PCCM clients are free to choose the physician who will perform their THSteps medical checkups. Under HMOs this same freedom of choice exists; however, providers bill the HMO rather than TMHP. While preventive services are available in managed care, those provided to clients from birth to 21 years of age must be completed as THSteps medical checkups, meet program requirements, and be submitted with appropriate THSteps procedure codes and THSteps provider identifiers. Note: Diagnosis and treatment of problems must be provided either by the client s primary care provider or by a provider referred by the client s primary care provider. If a THSteps medical checkup is performed by a provider who is not the client s primary care provider, the results of the medical checkup should be forwarded to the client s primary care provider so that the client s medical record can be updated, in keeping with the medical home concept If an enrolled medical checkup provider wants to discontinue participation, the provider must send written notification to the managed care health plan, as well as to TMHP at the following address: Texas Medicaid & Healthcare Partnership Provider Enrollment PO Box Austin, TX Refer to: "Provider Enrollment" on page 43-5 for more information about enrollment. "Managed Care" on page CPT only copyright 2005 American Medical Association. All rights reserved.

7 Texas Health Steps (THSteps) Eligibility for a Medical Checkup Through outreach THSteps staff (the Department of State Health Services [DSHS], the Texas Health and Human Services Commission [HHSC], or contractors) encourage clients to use THSteps preventive medical checkup services when they first become eligible for Medicaid and each time thereafter when they are periodically due or overdue for their next medical checkup. Providers are encouraged to perform checkups on any client they identify as eligible for medical checkups. They also are encouraged to notify clients when they are due for the next checkup according to the THSteps periodicity schedule. The client is periodically eligible for medical checkup services based on the THSteps Periodicity Schedule. A THSteps statement under the client s name on the regular client Medicaid Identification (Form H3087) and the State of Texas Access Reform (STAR) Identification (Form H3087 STAR) indicates the THSteps services for which the client is currently eligible. A check mark on the Medicaid Identification (Form H3087) and the STAR Identification (Form H3087 STAR) indicates eligibility for the particular service, such as eye exam, eye glasses, hearing aid, intermediate care facility for the mentally retarded (ICF-MR) dental, prescriptions, and medical services. A blank space denotes that the client is not eligible for the particular service based on available data. Checkups provided when a THSteps statement does not indicate a medical checkup is due must be billed as an exception to the periodicity schedule. Refer to: "Exceptions to Periodicity" on page 43-9 for further details about billing for a checkup performed as an exception to periodicity. Although the Medicaid Eligibility Verification (Form H1027) identifies eligible clients when the client Medicaid Identification (Form H3087) is lost or has not yet been issued, Form H1027 does not indicate periodic eligibility for medical checkup services. Providers can call the TMHP Contact Center at or check the TMHP website at to verify a client s periodic eligibility for medical checkup services Newborn Eligibility A newborn child may be eligible for Medicaid for up to one year if the child s mother is: Receiving Medicaid at the time of the child s birth Eligible for Medicaid or would be eligible if pregnant Living with the child If the newborn has Medicaid coverage, it is not acceptable for a provider to require a deposit for newborn care from the guardian. The child s eligibility ends if the child s mother relinquishes her parental rights or if it is determined that the child is no longer part of the mother s household. The hospital or birthing center must report the birth to HHSC Eligibility Services at the time of the birth. If the hospital or birthing center notifies HHSC Eligibility Services that a newborn child was born to a Medicaideligible mother, then the hospital caseworker, mother, and attending physician (if identified) should receive a Medicaid Eligibility Verification (Form H1027) from HHSC a few weeks after the child s birth. The H1027 form includes the child s Medicaid number and effective date of coverage. After the child has been added to the HHSC eligibility file, a client Medicaid Identification (Form H3087) is issued. Note: Claims submitted for services provided to a newborn eligible for Medicaid must be filed using the newborn child s Medicaid number. Claims filed with the mother s Medicaid number cause a delay in reimbursement. The Medicaid number on the Medicaid Eligibility Verification (Form H1027) may be used to identify newborns eligible for Medicaid. Refer to: "Medicaid Identification Form H3087" on page Reimbursement Physicians are reimbursed for THSteps medical checkups and administration of immunizations in accordance with 1 TAC High volume payments to physicians are detailed in "Additional Payments to High-Volume Providers" on page 2-6 of this manual. THSteps medical checkups provided in an FQHC are reimbursed in accordance with 1 TAC THSteps medical checkups may be billed electronically or on a CMS-1500 claim form. Providers may request information about electronic billing or the claim form by contacting the TMHP THSteps Contact Center at Only services provided are considered for reimbursement. In accordance with federal policy, the Texas Medicaid Program and Medicaid clients cannot be charged when a client does not keep an appointment. The $70 THSteps medical checkup fee includes payment for tuberculosis (TB) skin tests and collecting the blood specimens for all required laboratory services included on the checkup periodicity schedules. Vaccines, TB skin tests and supplies, laboratory supplies, and laboratory testing are made available free of charge to medical checkup providers through DSHS. THSteps visits will not be reimbursed if performed through telemedicine. A $5 reimbursement is made for each immunization administered during the medical checkup visit. Combined antigen vaccines (e.g., DTaP or MMR) are reimbursed as one dose. Vaccines that are available through the DSHS Texas Vaccine for Children (TVFC) Program (from birth through 18 years of age) will not be reimbursed. No reimbursement is made for performing the TB skin test, but all clients should be brought back to the provider's office for a THSteps follow-up visit to read the skin test. 43 CPT only copyright 2005 American Medical Association. All rights reserved. 43 7

8 Section Medical Checkup A complete THSteps medical checkup is reimbursed at a maximum fee of $70 for children covered under the traditional fee-for-service Medicaid Program. Except for PCCM, reimbursement for THSteps medical checkups for children enrolled in the Medicaid Managed Care Program must be contractually negotiated between the provider and the child s or adolescent's managed care organization (MCO). PCCM providers are reimbursed at the traditional fee-forservice rate of $70. Providers in areas of the state covered by Medicaid Managed Care should refer to "Managed Care" on page 7-1 for more information about reimbursement and referrals. All components of the THSteps medical checkup are included in the reimbursement for the visit. A provider's billing for services is acknowledging the completion of a comprehensive medical checkup in accordance with THSteps policy. The visit is a comprehensive medical checkup and must include all age-appropriate assessments, screenings, immunizations, and laboratory tests as indicated on the periodicity schedule. Specifically, a component with an available Current Procedural Terminology (CPT) code is not reimbursed separately on the same day as a medical checkup. Information concerning the components required at specific ages can be found on pages and for birth through 20 years of age. Services performed in an FQHC or RHC setting are paid an all-inclusive rate per visit. For services performed in an RHC, providers must use the appropriate national place of service code (POS) 72 for an RHC setting. An FQHC provider must bill all THSteps visits with modifier EP in addition to the modifiers used to identify who performed the medical checkup. Refer to: "CMS-1500 Claim Filing Instructions" on page 5-24 for billing instructions. Reminder: A complete checkup is an assessment provided in accordance with mandated procedures and the narrative standards outlined for each procedure. Incomplete medical checkups are not reimbursed. Providers may bill up to nine visits, regardless of the date of the last medical checkup, in the first two years of life. All of the checkups listed on the periodicity schedule have been developed based on recommendations of the American Academy of Pediatrics (AAP). In Texas, the THSteps program has modified the AAP periodicity schedule based on the scheduling of a test in federal EPSDT regulations or other programs or to meet the population s needs. When the THSteps provider who performs the checkup determines that a referral for diagnosis and treatment is necessary for a condition found during the checkup, the referral should be made to a provider who is qualified to perform diagnostic or treatment services. If the provider performing the medical checkup can provide treatment for the identified condition, a separate claim for an established patient office visit may be submitted on the same day as the checkup with an appropriate established patient CPT code for the diagnosis and treatment of the identified problem. Exception: Medicaid Managed Care clients must be referred to their designated primary care provider for further treatment or referral. Refer to: "Referrals for Medicaid-Covered Services" on page for information about treatment or acute care visits on the same day as a medical checkup or other referral information. For the acute care claim, providers must bill the CPT codes for evaluation and management of established patients with an appropriate diagnosis documented. Often minor illnesses or conditions (e.g., follow-up of a mild upper respiratory infection) during the THSteps medical checkup do not warrant additional billing Newborn Examination Inpatient newborn examinations billed with procedure codes and are counted as THSteps medical checkups and must include all the necessary components. The required components of the initial THSteps newborn checkup must meet THSteps requirements and must include the following documentation: History and physical examination Length, height, weight, and head circumference Sensory screening (vision and hearing appropriate to age) Hepatitis B immunization Mandated initial newborn screen at hours of age Health education with the parents or a responsible adult who is familiar with the child s medical history. Health education by the nursing staff, individually or in a class, is acceptable Note: In Texas the newborn hearing screening is included in the in-hospital newborn exam. Providers must include and document the required components when billing procedure codes or to the Texas Medicaid Program. If the provider chooses to do a brief examination (not including all the above components), the provider may bill procedure code or with modifier 52, which does not count as a THSteps checkup. Providers billing these newborn codes are not required to be THSteps providers, but they must be enrolled as Medicaid providers. TMHP encourages THSteps enrollment for all providers that offer a medical home for clients and provide them with well-child care and immunizations. Physicians and hospital staff are encouraged to inform parents eligible for Medicaid that the next THSteps checkup on the periodicity schedule should be scheduled at 1 to 2 weeks of age and that regular checkups should be scheduled during the first year CPT only copyright 2005 American Medical Association. All rights reserved.

9 Texas Health Steps (THSteps) Medical Checkup, First 6 Days of Life To encourage early checkups for high-risk but healthy newborns, providers may bill a THSteps medical checkup in the first six days of life as an exception to periodicity. A physical examination is important if the child has been discharged early from the hospital or if the infant was born outside of a hospital. A home visit may be especially helpful for first-time mothers. The first regular checkup should still be scheduled at 1 to 2 weeks of age, is also reimbursable, and should include the second newborn screen. The exception-to-periodicity checkup performed in the first six days of life may be performed in a clinic, provider s office, or the family s home. If the checkup is performed in the home, the provider must be designated by the discharging physician or the medical home physician before discharge and must provide a timely report of findings and recommendations to the infant s medical home. Refer to: "Medical Home Concept" on page A THSteps medical checkup in the first six days of life, billed as an exception to periodicity, must include the following: Neonatal and family history Review of systems Height, weight, and head circumference Physical and nutritional assessment Vision and hearing screening Age-appropriate immunization Assessment of the mental health status of the infant and mother Anticipatory guidance The metabolic screening should only be obtained if not obtained before discharge from the hospital. The repeat metabolic screening should be completed at the one- or two-week visit. If a potential or confirmed medical problem requires monitoring, it is recommended that the infant be seen in a clinic or medical provider s office, and Medicaid should be billed using codes for a sick child Exceptions to Periodicity Payment is made for medical checkups that are exceptions to the periodicity schedule to allow for services under the following categories: Medically necessary (such as developmental delay or suspected abuse) Environmental high-risk (such as sibling of a child with elevated blood lead) Required to meet state or federal exam requirements for Head Start, daycare, foster care, or pre-adoption Required for dental services provided under general anesthesia Medically necessary checkup in the first six days of life Refer to: "CMS-1500 Claim Filing Instructions" on page 5-24 for billing instructions. THSteps medical exception to periodicity services must be billed with the same procedure codes, provider type, modifier, and condition indicators as a medical checkup. Additionally, providers must use modifiers SC, 23, and 32 to indicate the exception. Note: Modifier 23 refers to children receiving a medical checkup prior to general anesthesia related to dental procedures. Note: The visit is not required to be billed as an exception when the child is eligible for Medicaid or the child is new to Medicaid and the checkup will be the initial medical checkup. If an exception is not required, the claim should be submitted without the use of the modifiers Follow-up Medical Checkup Visit A follow-up checkup visit is reimbursed at a maximum fee of $6 except for services performed in an RHC or FQHC setting. Follow-up checkups may be needed when required to complete necessary procedures related to the THSteps checkup (e.g., to read a TB skin test, transportation and outreach work required by the provider to read a TB skin test, administering immunizations in cases where the child s immunizations were not up-to-date or medically contraindicated on the initial visit, and repeating laboratory work). An additional $5 administrative fee is paid for each immunization (injection), except for services performed in an RHC or FQHC setting. Combined antigen vaccines (e.g., DTaP or MMR) are reimbursed as one dose. A return visit to follow up on treatment initiated during the screen or to make a referral is not to be filed as a follow-up visit. Follow-up visits may not be billed on the same day as a THSteps visit. Refer to: "CMS-1500 Claim Filing Instructions" on page A THSteps medical checkup follow-up visit must be billed with a THSteps provider identifier to be considered a THSteps visit. FQHCs must bill the same procedure with modifier EP. When billing for a THSteps medical checkup follow-up visit, providers must use national procedure code S Usually, the necessary components are minimal and may not require the presence of a physician. Typically, five minutes are spent performing or supervising these services Verification of Medical Checkups The first source of verification that a THSteps medical checkup has occurred is a paid claim or encounter. THSteps encourages providers to file a claim either electronically or on a CMS-1500 claim form as soon as possible after the date of service, as the paid claim updates client information, including the Medicaid Identification. 43 CPT only copyright 2005 American Medical Association. All rights reserved. 43 9

10 Section 43 The second source of acceptable verification is a physician s written statement that the checkup occurred. If the provider chooses to give the client written verification, it must include the child s name, Medicaid ID number, date of the medical checkup, and a notation that a complete THSteps medical checkup was performed. If neither the first nor the second source of verification is available, a THSteps staff member may contact the provider s office for verification Claims Information Procedure Coding for THSteps Medical Checkups THSteps medical checkups must be billed with the appropriate procedure codes (S-99381, S-99382, S-99383, S-99384, S-99385, S-99391, S-99392, S-99393, S-99394, and S-99395). Procedure codes S and S are restricted to clients 18 through 20 years of age for a THSteps medical checkup. Condition indicators must be used to describe the results of the checkup. A condition indicator must be entered on the claim with the periodic medical checkup visit procedure code. Additional indicators are required based on whether a referral was made or not. If a referral was made, providers must use the Y referral indicator. If no referral is made, providers must use the N referral indicator. Procedure Codes for THSteps Medical Checkups The ST condition indicator should only be used when a referral is made to another provider or the client must be rescheduled for another appointment with the same provider. It does not include treatment initiated at the time of the checkup. Providers must use type of service (TOS) S when billing for the following THSteps medical checkup services: TOS S S Procedure Codes S-99381, S-99382, S-99383, S-99384, and S (New client preventive visit) or S-99391, S-99392, S-99393, S-99394, and S (Established client preventive visit) S-99381, S-99382, S-99383, S-99384, and S (New client preventive visit) or S-99391, S-99392, S-99393, S-99394, and S (Established client preventive visit) Referral Indicator N (No referral given) Y (Yes THSteps/ EPSDT referral was given to the client) Condition Indicator NU (Not used) S2 (Under treatment) or ST (New services requested) Modifiers AM, SA, TD, and U7 must be used to indicate the practitioner who performed the unclothed physical examination on the medical screen. Services performed in an FQHC or RHC setting are paid an all-inclusive rate per visit. If services are performed in an RHC, providers must use the appropriate national place of service code (72) for an RHC setting. An FQHC provider must bill all THSteps visits with modifier EP in addition to one of the above modifiers used to identify who performed the medical checkup. Submit claims for THSteps medical services to TMHP in an approved electronic format or on a CMS-1500 claim form Immunizations Billed Within THSteps Medical Checkups, Exception to Periodicity, and Follow-Up Visit Diagnosis code V202 is required to be used with the combination of the procedure code and the appropriate vaccine administration code from the table located in Section Providers must use their THSteps provider identifier and TOS S Immunizations Billed Outside of THSteps Medical Checkups, Exception to Periodicity, or Follow-Up Visit Diagnosis code V069 is required to be used with the procedure codes , , , , , , , and in combination with the appropriate vaccine administration code in the following table. Providers must use their regular Medicaid provider identifier and TOS 1. For all immunizations, if only one immunization is administered during a checkup or visit, providers should bill administration procedure code 1/S or 1/S with a quantity of 1 in addition to the appropriate national code that describes the immunization administered. If two or more immunizations are administered, providers should bill administration procedure codes 1/S-90465, 1/S-90467, 1/S-90471, or 1/S with a quantity of 1, procedure codes 1/S-90466, 1/S-90468, 1/S-90472, or 1/S with a quantity of 1 or more (depending on the number of vaccines administered), and the appropriate national procedure codes that describe each immunization administered. The procedure codes that identify each vaccine are considered informational but are required on the claim. Vaccine Procedure Codes 1/S /S /S /S /S /S /S /S /S /S /S /S /S /S /S /S /S /S /S /S /S /S CPT only copyright 2005 American Medical Association. All rights reserved.

11 Texas Health Steps (THSteps) Vaccine Procedure Codes /S /S /S /S Exception: Medical contraindications and exclusions from immunizations for reasons of conscience (including a religious belief and parental/client refusal) are the only acceptable reasons for not administering immunizations. Refer to: Immunizations Overview on page H-2 for exclusions from immunizations Billing Providers should bill the usual and customary fee. Providers are reimbursed the lesser of the billed amount or the maximum allowable fee. THSteps providers do not have to bill private insurance; they can bill TMHP directly. A medical checkup has a maximum fee of $70, immunization administration (per injection) has a maximum fee of $5, and a medical checkup follow-up visit has a maximum fee of $6. Important: All procedures, including the informational-only procedures, must have a billed amount associated with each procedure listed on the claim. The procedure code on the claim form indicates whether referral for diagnosis and treatment is needed for eligible clients; consequently, all information must be accurate. The following are instructions for completing the CMS-1500 form when billing a THSteps medical checkup: The diagnosis code in Block 21.1 of the CMS-1500 is always V202. Electronic billers also use V202. Type of service on the CMS-1500 (Block 24C) is always S. POS on the CMS-1500 (Block 24B) is 1, Alpha 0, or 11 for electronic billers. For services provided in an RHC setting, providers must use national POS 72. Patient records must reflect that each of the required screening procedures was completed in accordance with the medical checkup periodicity schedules based on the child s age. Providers must record the following on the CMS-1500 claim form to receive reimbursement for a medical checkup: Appropriate THSteps medical checkup procedure code (all ages) TB skin test procedure code, if administered (1 through 20 years of age) Immunization administration and vaccine procedure code(s) if administered (all ages) Condition indicators Provider type modifiers EP modifier, if appropriate Submit claims to the following address: Texas Medicaid & Healthcare Partnership PO Box Austin, TX Claim Filing Resources Refer to the following sections and/or forms for claims filing information: Resource CMS-1500 Claim Filing Instructions 5-24 TMHP Electronic Claims Submission 5-10 Communication Guide A-1 Automated Inquiry System (AIS) Page Number THSteps Medical Checkup Facilities All THSteps medical checkup policies apply to examinations completed in a physician s office, a health department, clinic setting, or in a mobile/satellite unit. Enrollment of a mobile/satellite unit must be under a physician or clinic name. Mobile units can be a van or any area away from the primary office and are considered extensions of that office and are not separate entities. The physical setting must be appropriate so that all elements of the checkup can be completed. For specific information, review the periodicity schedules and narrative explaining the schedules Medical Home Concept HHSC and DSHS encourages providers participating in the Texas Medicaid Program to practice the medical home concept for clients with Medicaid. To realize the maximum benefit of health care, each family and individual needs to be a participating member of a readily identifiable, community-based medical home. The medical home provides primary medical care and preventive health services and is the individual s and family s initial contact point when accessing health care. It is a partnership among the individual and family, health care providers within the medical home, and extended network of consultative and specialty providers with whom the medical home has an ongoing and collaborative relationship. The providers in the medical home are knowledgeable about the individual s and family s specialty care and health-related social and educational needs and are connected with necessary resources in the community that will assist the family in meeting those needs. xiii TMHP Electronic Data Interchange (EDI) 3-1 Diagnosis and Treatment (Referral from D-11 THSteps Checkup) Claim Form Example THSteps Complete Medical Checkup D-34 (CMS-1500) Claim Form Examples Acronym Dictionary F-1 43 CPT only copyright 2005 American Medical Association. All rights reserved

12 Section 43 When referring for consultation, specialty/hospital services, and health and health-related services, the medical home maintains the primary relationship with the individual and family, keeps abreast of the current status of the individual and family through a planned feedback mechanism, and accepts them back into the medical home for continuing primary medical care and preventive health services Continuity of Care and the Medical Home The individual providing the medical checkup must ask the parents whether the child has a private physician or a medical home where the child usually receives medical care. If the child s medical home provides THSteps checkups, it is in the child s and family s best interest for providers to encourage that relationship. If the family has a medical home but prefers to have their checkup done by another provider, that provider should send a copy of the THSteps medical checkup records examinations to the primary care provider. If the medical checkup provider is unable to offer a medical home to the child, that provider must enter into written agreements with providers who are willing to offer medical homes Mobile Units and the Medical Home If a provider has mobile units functioning in different communities, the agreements with providers who are willing to offer the medical home must be signed in each community so that children are referred to local providers for medical homes. Providers with mobile units must advise families that they have freedom of choice concerning who completes the medical checkups THSteps Dental Services Access to THSteps dental services is mandated by Medicaid and provides reimbursement for the early detection and treatment of dental health problems for Medicaid-eligible clients younger than 21 years of age. THSteps dental service standards were designed to meet federal regulations and to incorporate the recommendations of representatives of dental professional groups in the state. OBRA of 1989 mandated the expansion of the federal EPSDT program to include any service that is medically necessary and for which federal financial participation (FFP) is available, regardless of the limitations of the Texas Medicaid Program. This expansion is referred to as the CCP. Refer to: "THSteps-CCP Overview" on page for more information How the THSteps Dental Program Works THSteps-designated staff (HHSC, DSHS, or contractor), through outreach and information, encourages the parents or caregivers of eligible children to use THSteps dental checkups and prophylactic care when children first become eligible for Medicaid and each time children are periodically due for their next dental checkup. Upon request THSteps-designated staff (HHSC, DSHS, or its contractor) assists the parents or caregivers of eligible children with scheduling of appointments and transportation. Medicaid clients have freedom of choice of providers and are given names of enrolled providers. Call the DSHS THSteps Hotline at for a list of THSteps dental providers in a specific area. When a child is eligible for a THSteps dental checkup, a message is present on the Medicaid Identification (Form H3087 or H3087 STAR) under the child s name. If the child or caregiver believes the child is due for a dental checkup and a message is not present, the provider may contact TMHP through the TMHP website at or the Automated Inquiry System (AIS) at to verify that the child is due for a dental checkup. Children may receive an initial THSteps dental checkup at 12 months of age and a periodic dental checkup every 6 months thereafter, through 20 years of age. Children younger than 12 months of age are not eligible for routine dental examinations; however, they may be referred when a medical checkup identifies the medical necessity for dental services. All THSteps clients younger than 21 years of age can be seen by the dentist at any time for emergency dental services for trauma, early childhood caries, or any other appropriate dental or therapeutic procedure. Clients up to 21 years of age may self-refer for dental services. Note: Clients enrolled in Medicaid Managed Care are required to choose a provider in their health plan's network. The health plan does not reimburse for services rendered by nonparticipating providers. Please contact the specific health plan for enrollment information Vision Services Appropriate vision screening is a mandatory part of each medical checkup visit. Additionally, vision exams and services include eye examinations with refraction and eyeglasses. Eyeglasses are available once every 24 months. Eye examinations are available once per state fiscal year (SFY) (September 1 through August 31). This limit does not apply if the examination is for aphakia, disease, injury of the eye, or if medically necessary (for eyeglasses, defined as a 0.5 diopter change in one eye). Replacement of lost or destroyed eyewear is a benefit for THSteps-eligible clients CPT only copyright 2005 American Medical Association. All rights reserved.

13 Texas Health Steps (THSteps) Refer to: "Vision Screening" on page for information about vision screening for children and adolescents. "Vision Care (Optometrists, Opticians)" on page 45-1 for more information Hearing Services Appropriate hearing screening is a mandatory part of each medical checkup. Additionally, hearing exams and services, including hearing aids, are available when medically necessary. Payment for services to eligible clients received through approved Program for Amplification for Children of Texas (PACT) providers is made through PACT at DSHS. Refer to: "Inpatient Hearing Screening" on page for information about hearing screening for children and adolescents Referrals for Medicaid-Covered Services When a provider performing a checkup determines that a referral for diagnosis or treatment is necessary for a condition found during the medical checkup, that information must be discussed with the parents. A referral should be made to a provider who is qualified to perform the necessary diagnosis or treatment services. Medicaid Managed Care clients must be referred to their designated primary care provider for further treatment or referral. A provider needing assistance to find a specialist that accepts patients with Medicaid coverage can call the DSHS THSteps Hotline at Effort should be made to maintain continuity of care including follow-up to determine that the appointment was kept and that the provider receiving the referral has provided diagnosis and recommendations for further care to the referring provider. If the provider performing the medical checkup can provide treatment for the condition identified, a separate claim (CMS-1500 or HCFA-1450 [UB-92]) may be submitted for the same date of service as the checkup with an appropriate established patient office visit for the diagnosis and treatment of the identified problem. For the acute care claim, an appropriate level CPT code for evaluation and management (E/M) of established patients should be selected with the diagnosis supporting this additional billing documented. Not all minor illnesses or conditions, such as follow-up of a mild upper respiratory infection, identified during the THSteps medical checkup warrant additional billing. The billing of an additional office visit is only appropriate if the additional evaluation and treatment is required and performed for the identified condition(s). This additional service, since it is billed as an acute care claim to Medicaid, is independent of the THSteps medical checkup and is viewed as a stand-alone service. Consequently, the medical record must contain documentation that supports the medical necessity and the level of service of the E/M code submitted for reimbursement. In addition to referrals for conditions discovered during a checkup or for specialized care, the following referrals may be used: Routine Dental Referrals. Routine dental referrals are required for all children at 1 year of age and every six months thereafter through 20 years of age (see "THSteps Dental Services" on page 43-12). Children younger than 12 months of age are not eligible for routine dental examinations; however, they may be referred when a medical checkup identifies the medical necessity for dental services. Children younger than 12 months of age also can be seen for emergency dental services by the dentist at any time for trauma, baby bottle tooth decay, or other oral health problems, such as early childhood caries. Clients up to 21 years of age may also self-refer for dental care. Emergency Dental Referrals. If a medical checkup provider identifies an emergency need for dental services, such as bleeding, infection, or excessive pain, the client may be referred directly to a participating dental provider. Emergency dental services are covered at any time for all THSteps clients eligible for Medicaid up to 21 years of age. Note: In cases of both emergency and nonemergency dental services, clients have freedom of choice in selecting a dental provider who is participating in the THSteps Dental Program. Family Planning and Genetic Services Referrals. For people eligible for Medicaid needing genetic services or family planning services, a referral should be made. Information about Medicaid-covered genetic services is available in "Genetic Services" on page 22-1 and information about family planning services is available in "Family Planning Services" on page If the THSteps medical provider also provides family planning, the provider may inform the client of the availability of these services. THSteps-CCP Services Referrals. CCP benefits are medically necessary services for which FFP is available and may not currently be covered by Texas Medicaid (e.g., orthotics, private duty nursing, and others), as well as expanded coverage of current services that have limitations. Refer to: "Hearing Referrals" on page for referrals following a hearing screening. "Medicaid Managed Care" on page 7-4 for more information on referrals for providers in areas of the state covered by Medicaid Managed Care. "THSteps-CCP Overview" on page for more information. 43 CPT only copyright 2005 American Medical Association. All rights reserved

14 Section Texas Vaccines for Children Program For Medicaid children younger than 19 years of age, the TVFC program provides free vaccines that are routinely recommended according to the Recommended Childhood Immunization Schedule (Advisory Committee on Immunization Practices [ACIP], AAP, and the American Academy of Family Physicians [AAFP]). To obtain free vaccines for children birth through 18 years of age, THSteps providers must enroll in TVFC at DSHS. There is no reimbursement to providers for vaccines available from TVFC. Refer to: Appendix H, Immunizations on page H-1 and TVFC Provider Enrollment (3 Pages) on page C-97 for more information about enrolling as a TVFC provider Benefits and Limitations Medical checkup services are covered for clients younger than 21 years of age when delivered in accordance with the THSteps Medical Checkups Periodicity Schedule, which specifies the screening procedures recommended at each stage of the client s life and identifies the time period based on the client s age when medical checkup services are reimbursable. Important: Providers should treat each THSteps visit as the only opportunity for a client s comprehensive assessment. In acknowledgment of the practical situations that occur in the office or clinic settings, the periodicity schedule published in this manual has stressed the philosophy that the components of the THSteps medical checkup should be completed according to the individual child s appropriate needs. If a component cannot be completed because of a medical contraindication of a child s condition, then a follow-up visit is necessary. Client eligibility for a medical checkup is determined by the client s age on the first day of the month. If a client has a birthday on any day except the first day during the month, the new eligibility period begins on the first of the following month. If a client turns 21 years of age during a month, the client continues to be eligible for THSteps services through the end of that month. If components of the THSteps checkup have been provided one month preceding the child s birthday month and the medical checkup occurs in the following month, providers should clearly refer to that previous documentation, including the date(s) of service in the current clinical notation, and add appropriate new documentation for the checkup currently being billed. All components of the THSteps medical checkup are included in the reimbursement of the visit. The visit is a comprehensive medical checkup and must include all assessments, screenings, immunizations, and laboratory tests as indicated on the periodicity schedule. Specifically, when there is an available CPT code for a component, it is not reimbursed separately on the same day as a medical checkup. Sports examinations are not a covered Medicaid service. If the child or adolescent is due for a THSteps medical checkup and a comprehensive medical checkup is completed, a THSteps medical checkup may be reimbursed. Providers should call TMHP THSteps Medical Inquiries at with questions about the THSteps medical checkups. The line is available from 7 a.m. to 7 p.m., Central Time, Monday through Friday. Clients that are eligible for Medicaid and have questions about the THSteps program should call the DSHS THSteps Hotline at Clients with questions about their Medicaid eligibility for the THSteps program should be directed to their caseworker at the local HHSC office or site Information and Assistance Assistance with Program Concerns Providers that have questions, concerns, or problems with program rules, policy, or procedure should contact DSHS regional program staff. THSteps staff contact numbers can be found in Appendix A, Section A.7 DSHS Health Service Region Contacts on page A-8, or on the THSteps website, or by calling THSteps at THSteps regional staff make routine contact with providers to educate and assist providers with THSteps program policies and procedures Assistance with Claims Concerns Providers with questions, concerns, or problems about claims should contact the TMHP Contact Center at For regional contact information, providers can refer to the TMHP website at then click on the Regional Support link Clinical Information This section contains specific information about medical and dental services. For more specific administrative information, see "THSteps Medical and Dental Administrative Information" on page Documentation of Completed Checkups To assure completion of comprehensive medical checkups and the quality of care provided, providers must document all components of the THSteps medical checkups as they are completed. Clinical charts are subject to quality review activities including random chart review and focused studies of well-child care. In acknowledgment of the practical situations that occur in the office or clinic settings, the AAP has stressed the philosophy that the components of all medical checkups CPT only copyright 2005 American Medical Association. All rights reserved.

15 Texas Health Steps (THSteps) should be performed that are appropriate to the needs of the individual child. Consequently, completion of all recommended components of a THSteps medical checkup may require follow-up checkups. The Centers for Medicare & Medicaid Services (CMS) has clarified, in its Medicaid Guide To State Entities, the following expectations for the content of comprehensive preventive health visits: Comprehensive health history, including developmental and nutritional assessment. Comprehensive unclothed physical examination, including graphic recording of head circumference. Appropriate immunizations as indicated in the Recommended Childhood and Adolescent Immunization Schedule - United States. Age-appropriate laboratory tests for anemia, lead poisoning, and newborn screening. Health education, including anticipatory guidance, is required. Age-appropriate vision and hearing screening. Direct referral to dental checkups beginning at 12 months of age THSteps Medical Checkups Periodicity Schedule The client is periodically eligible for medical checkup services based on the THSteps medical checkups periodicity schedule. All the checkups listed on the periodicity schedule have been developed based on recommendations of the AAP. The AAP continues to emphasize the importance of separate counseling and anticipatory guidance for the child and the accompanying parent/ guardian during the adolescent years. In Texas the THSteps program has modified the AAP periodicity schedule based on the scheduling of a test in federal EPSDT regulations, state statutes or other programs, or to meet the population s needs. CPT only copyright 2005 American Medical Association. All rights reserved

16 43 16 CPT only copyright 2005 American Medical Association. All rights reserved THSteps Medical Checkups Periodicity Schedule for Infants, Children, and Adolescents (Birth Through 20 Years of Age) The columns across the top of the schedule indicate the age a client is periodically eligible for a medical checkup. The first column on the left of the chart identifies each procedure that must be performed at each appropriate age. (See Key at bottom of page and Footnotes on the following page.) History Weeks Months Years Age 1 Inpatient Family Neonatal Physical, Mental Health, and Developmental Behavioral Risk 2 Physical Examination 3 Measurements Height, Weight Body Mass Index (BMI) Fronto-Occipital Circumference Blood Pressure Nutrition Developmental 4 Mental Health Sensory Screening 5 Vision Screening 5a Hearing Screening 5b Tuberculosis Screening 6 Laboratory 7 Newborn Hereditary/Metabolic 8 Testing Hgb or Hct 9 Lead Screening 10 Hemoglobin Type 11 STD Screening 14 HIV Screening 15 Pap Smear 16 Hyperlipidemia 12 Glucose 13 Immunizations 17 Dental Referral 18 Anticipatory Guidance 19 Key Required, unless medically contraindicated or because of parent s reasons of conscience including a religious belief. Required as above, unless already provided on a previous checkup at the required age and documented on the health record with the date of service. If answers on high risk assessment questionnaires or other screening show a risk factor, further screening is required. Refer to Footnotes for more information about marked items. Section 43

17 CPT only copyright 2005 American Medical Association. All rights reserved THSteps Medical Checkups Periodicity Schedule for Infants and Children (Birth Through 20 Years of Age) (continued) Footnotes 1. If a child comes under care for the first time at any point on the schedule or if any procedures are not accomplished at the appropriate age, the client must be brought up-to-date with required procedures as soon as possible. 2. Screening for adolescent lifestyle risk factors is to include eating disorders, sexual activity, alcohol (and other drug use), tobacco use, school performance, depression, and risk of suicide. 3. An age-appropriate complete unclothed physical exam is required at each checkup. Older children are to be appropriately draped. For adolescents who are sexually active, a pelvic exam should be part of the examination. 4. Developmental screening: a. Medical checkups completed by physicians, physician assistants, and advanced practice nurses (pediatric nurse practitioners and family nurse practitioners) conducting THSteps checkups for children birth up to and including the six-year medical check-up must include: A standardized developmental screen (the provider s choice of observational or parent questionnaire) for a child between 9 through 12 months of age, 18 through 24 months of age, and every other year thereafter. Standardized screening should also be conducted if a parent expresses concern about the child s developmental progress. Developmental screening at all other visits to include a review of milestones (gross and fine motor skills; communication skills, speech-language development; self help/care skills; social, emotional, and cognitive development) and mental health. b. Registered nurses conducting THSteps medical checkups for children birth up to and including the six-year medical check-up are required to conduct: A standardized observational screen for children in the following age groups: 9 through 12 months of age; 18 through 24 months of age; and if the child does not have a record of a standardized observational developmental screen, again between 24 months up to and including the six-year medical check-up. A standardized parent questionnaire at all other periodic visits birth up to and including the six-year medical check-up or when a parent expresses concern about the child s developmental progress. 5. Sensory screening: a. Vision: Birth through 2 years of age Screening includes history of high-risk conditions, observation, and physical examination. Ages 3 through 10, 12, 15, and 18 years of age Screening includes administration of an age-appropriate vision chart. Documentation of test results from a school vision screening program may be used if conducted within 12 months of the checkup. b. Hearing: Birth through 3 years of age Screening includes history, observation, and screening by use of the Parent Hearing Questionnaire. Ages 4 through 10, 12, 15, and 18 years of age A puretone audiometer should be used to screen hearing at checkups. Subjective screening may be completed at all other checkups. Documentation of results from a school audiometric screening program may be used if conducted within 12 months of the checkup. 6. In areas of low prevalence, administer the Tuberculosis (TB) Questionnaire annually beginning at 1 year of age. In areas of high prevalence, administer the TB skin test at 1 year of age, once between 4 through 6 years of age, and once between 11 through 17 years of age. Administer the TB Questionnaire annually beginning at 2 years of age and thereafter at other checkups. All clients should return for the provider to read the skin test. The TB Questionnaire is available in the Texas Medicaid Provider Procedures Manual (TMPPM). 7. All blood specimens are to be submitted to the DSHS Laboratory for analysis. 8. Newborn screening (hereditary/metabolic testing [hypothyroidism, PKU, galactosemia, sickle Hgb, and CAH]) is required by Texas law before hospital discharge and again between 1 and 2 weeks of age. Date and results of the second newborn screening are to be documented. 9. Hemoglobin (Hgb) and hematocrit (Hct) testing conducted at a Women, Infants, and Children (WIC) clinic or in a provider s office is acceptable within one month if date and value are documented. 10. Mandatory blood lead screening at 12 and 24 months of age. The Lead Exposure Questionnaire (available in the TMPPM) is acceptable at other visits. 11. If Hgb type has been performed previously and results are documented in the client s chart, it does not need to be repeated. Hgb type also is part of the newborn screening. 12. Hyperlipidemia screening should be completed for those at risk of increased levels of cholesterol (THSteps does not provide a formal questionnaire). 13. Children should be screened for risk of Type II diabetes. Fasting glucose screening should be obtained for those at risk of Type II diabetes. 14. For sexually active or high-risk adolescents, screening is to include evaluation for genital warts, cultures for gonorrhea and chlamydia, and blood test for syphilis. 15. While all adolescents should be screened for the risk of human immunodeficiency virus (HIV) infection, actual testing is voluntary. 16. The first Pap smear should be obtained at 21 years of age, 3 years from the onset of sexual activity, or at another age based on provider discretion. 17. Clients are not to be referred to the local health department for immunizations. Vaccines must be obtained from the Texas Vaccines for Children Program at DSHS and administered at the time of the checkup, unless medically contraindicated or because of parent s reasons of conscience including a religious belief. 18. Dental referrals are required for all patients beginning at 1 year of age. Patients are eligible for preventive dental checkups every six months thereafter, as well as emergency dental treatment at any time. 19. Counseling/anticipatory guidance is a required integral part of each checkup and must be face-to-face with the child s parent/caretaker and face-to-face with adolescents. Note: Additional information is available in the TMPPM. To quickly reference the subjects listed above, refer to the manual s Index or use the Search tool available in the electronic edition. Texas Health Steps (THSteps) 43

18 Section Medical Checkups for Infants, Children, and Adolescents (Birth Through 20 Years of Age) The following information lists descriptions and standards for each pediatric assessment and test that must be performed during a THSteps medical checkup in accordance with the periodicity schedule. The checkup includes face-to-face contact with the child s or adolescent s parent or guardian. Refer to: "THSteps Medical Checkups Periodicity Schedule for Infants, Children, and Adolescents (Birth Through 20 Years of Age)" on page History The child s or adolescent s initial history must include the following: Family medical history Neonatal history Physical and mental health history Developmental history Immunization history History of feeding or nutrition problems A complete review of body systems Subsequent histories may be specific for the child s or adolescent s age and health history. The history must be obtained from an adult caregiver familiar with the child and the child s health history. Preferably, the adolescent and the parent should be interviewed separately. Refer to: "Additional Adolescent Screening" on page for more history/screening information for adolescents Physical A complete physical examination is required at each visit, with infants totally unclothed and older children undressed and suitably draped. The physical examination must include assessment of the following systems: Skin Head, eyes, ears, nose, and throat (HEENT) Dental Heart Chest/lungs (includes breast exam for females past menarche) Abdomen (including hernia) Skeletal Neurological (includes evaluation of cerebral, cranial nerve, and cerebellar functions; motor and sensory systems; and reflexes) Genitalia (includes observation for appropriate sexual development and testicular exam for adolescent males) The unclothed physical examination must be completed by one of the following: A physician An NP A CNS An RN or licensed PA as stated in "Additional Education Requirements for Registered Nurses (RNs)" on page 43-6 Note: An RN may only perform under a physician s supervision. The physician ensures that the RN or PA has appropriate training and adequate skills to perform the procedures for which they are responsible Measurements The physical examination must include the following measurements: Length, for children approximately birth through 2 years of age Height, for children approximately 3 through 20 years of age Weight, for children birth through 20 years of age Body Mass Index (BMI) for children 2 through 20 years of age Head circumference, fronto-occipital circumference, for children younger than 2 years of age Blood pressure (for children 3 years of age and older, using the appropriate cuff size) The requirements for measurements other than blood pressure are to be compared to the National Center for Health Statistics growth charts to identify significant deviations from norms. These charts are available by calling THSteps at Refer to: The Women, Infants, and Children (WIC) website as a resource for information about measuring heights and weights at wichd/secure%2dpol/nutrassess.pdf. The requirements for measurements of blood pressure should be compared to Appendix I in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (2nd edition, revised), located at or Guidelines for Health Supervision III from the AAP Publication Department, located at Refer to: "Documentation of Completed Checkups" on page Nutritional Assessment The nutritional assessment is to be accomplished during the basic examination using the following methods: Ask questions about dietary practices to identify unusual eating habits (such as pica or extended use of bottle feedings) or diets that are deficient or excessive in one or more food groups CPT only copyright 2005 American Medical Association. All rights reserved.

19 Texas Health Steps (THSteps) Determine quality and quantity of individual diets (e.g., dietary intake, food acceptance, meal patterns, methods of food preparation and preservation, and utilization of food assistance programs like WIC and Texas Food Stamps). Conduct a complete physical examination, including an oral dental examination, paying special attention to general features, such as pallor, apathy, and irritability. Obtain accurate height and weight measurements and calculation of BMI as important indices of nutritional status. Perform laboratory screenings for anemia (hemoglobin and hematocrit), as indicated. Copies of the Nutritional Assessment Forms are listed in Appendix C of this manual. Refer to: Appendix C, 24-Hour Dietary Recall, Assessment for Infants (Birth 11 Months) (2 Pages) on page C Hour Dietary Recall and Assessment for Children (1 4 Years) (2 Pages) on page C Hour Dietary Recall and Assessment for Children (5 9 Years) (2 Pages) on page C Hour Dietary Recall and Assessment for Children (10 20 Years) (2 Pages) on page C-24. Risk Factors/Screening for Eating Disorders and Obesity The risk factors/screening for eating disorders and obesity assessment is to be accomplished in the basic examination, using the following methods: Adolescents should be asked about body image and dieting patterns. Adolescents should be assessed for organic disease, anorexia nervosa, or bulimia if any of the following are found: Weight loss greater than ten percent of previous weight Recurrent dieting when not overweight Use of self-induced emesis, laxatives, starvation, or diuretics to lose weight Distorted body image BMI below the fifth percentile Adolescents should have an in-depth dietary and health assessment to determine psychosocial morbidity and risk for future cardiovascular disease if they have a BMI equal to or greater than the 95th percentile for age and gender. Adolescents with a BMI between the 85th and 94th percentile are at risk for becoming overweight. A dietary and health assessment to determine psychosocial morbidity and risk for future cardiovascular disease should be performed on these youth if the following are true: Their BMI has increased by two or more units during the previous 12 months. There is a family history of premature heart disease, obesity, hypertension, or diabetes mellitus. They express concern about their weight. They have elevated serum cholesterol levels or blood pressure. If this assessment is negative, these adolescents should be provided general dietary and exercise counseling and should continue to be monitored annually Developmental Assessment Requirements for Developmental Screening by Physicians, Physician Assistants, Nurse Practitioners, and Clinical Nurse Specialists Medical checkups completed by physicians, PAs, and NPs or CNSs (pediatric or family specialities) for children birth through 6 years of age must include: A standardized developmental screen (the provider s choice of observational or parent questionnaire) for a child between 9 through 12 months of age, 18 through 24 months of age, and every other year thereafter, or when a parent expresses concern about the child s developmental progress. A developmental screen at all other visits, including a review of milestones (gross and fine motor skills, communication skills and speech-language development, self help and care skills, social, emotional, and cognitive development) and mental health. Requirements for Registered Nurses RNs conducting THSteps medical checkups for a child birth through 6 years of age are required to conduct a standardized observational screen for a child 9 through 12 months of age and 18 through 24 months of age. If the child does not have a record of a standardized observational screen, the child should receive one between 24 months through 6 years of age. A standardized parent questionnaire is required at all other periodic visits through the 6th year of age or when a parent expresses concern about the child s developmental progress. The combined use of a questionnaire and an observational screen reflects the child s developmental status more accurately than a single observational screen. If parents are unable to read or understand the questionnaire, the provider should use the parent questionnaire in an interview format. If the child fails the parent questionnaire, the provider should follow the instructions of the standardized screening tool concerning either observation testing or referral. Children 7 years of age and older should be screened by observation, history of school progress, and neurological assessment. Choice and Use of Tools A standardized screening tool is one that has been extensively evaluated through screening thousands of children and comparing the screen outcome of each individual child with the outcome of an in-depth developmental evaluation on that child. 43 CPT only copyright 2005 American Medical Association. All rights reserved

20 Section 43 If the screening tool specifies that training is required to use the tool, the screener must complete this training. Referrals for Developmental Assessment Referral for an in-depth developmental evaluation is determined by the criteria of the specific tool. The screener should understand and follow them. Referral for in-depth evaluation of development should be provided when parents express concern about their child s development, regardless of scoring on a standardized development screening tool. Referrals for in-depth evaluation of development must be made to an early childhood intervention (ECI) program (birth through 3 years of age) for suspected developmental delay, as required by state law. The provider also may refer to a pediatrician with skill in developmental assessment or the school district (3 years of age and older). Refer to: Texas Health Steps Statutory State Requirements on page K-1 for more information Mental Health Guidelines for Mental Health Screening The mental health screen is part of every comprehensive medical checkup. The age-specific interview tools and parent questionnaires are provided as an option for performing this screen. They are intended for use as part of a comprehensive pediatric assessment. If these interview tools are used outside the context of a comprehensive examination, the interviewer must remember to collect information usually gathered in a pediatric history: household members, prenatal/newborn history, child s health history, and family illnesses. The purpose of the mental health screen is to identify problems in any of six domains: feelings, behavior, social interactions, thinking, physical problems, and other problems that may include substance abuse. The provider choosing alternative screening tools or techniques should be certain to screen in these domains. Screening may reveal several minor problems or one or more significant problems that warrant referral for, or provision of, evaluation and, if indicated, treatment. In determining whether behaviors are serious enough to warrant referral, the screener must weigh the extent and intensity of the problems and explore the child s resiliency and positive behaviors. If the child has been or is under treatment for any mental health conditions, record that treatment in the child s medical record. Referral options may include parenting education programs, ECI programs (birth to 3 years of age), mental health evaluation and counseling, substance abuse programs, acute psychiatric hospitalization, or child protective services. The screener s responsibility is to identify and establish a referral relationship with these resources in the community. Screeners with special training and credentials allowing evaluation and treatment of childhood behavior problems, mental illness, or substance abuse may choose to provide these services rather than referring. Other screeners should refer to mental health specialists. Confidentiality The screener introduces the screen by explaining that the information provided will be held in strictest confidence unless the screener recognizes a situation that places the child or others in danger. Children older than 4 years of age should not be present when the screener questions the parent about possible abuse or neglect. Beginning when the child is about 10 years of age, questions about peer and family social interaction and substance abuse are explored with the child and parent separately. All parts of the screen are administered to the adolescent and their parent/caregiver separately. If observations of the child, the parent, or parent-child interaction lead the screener to suspect possible abuse or neglect, the screener must make a report to Child Protective Services. The report is required even though the screener may refer a family for evaluation or treatment of abuse/neglect. Behavior of Particular Concern Behavior generally expressive of mental health problems include those listed below. If the screener finds any of the following significant behaviors, further screening is unnecessary because referral is indicated: Setting fires Suicidal behavior or ideation Self-destructive activities Torturing animals Hurting other people Destroying property Loss of touch with reality Inappropriate sexual behavior Substance abuse Parental concern about their ability to maintain the child in the home Important: At the conclusion of a screening that is judged by the provider to be within regular limits, the screener should refer the child for a comprehensive mental health evaluation if the parent of an older child remains concerned that the child has mental health or behavior problems. Interview Tools/Referral Forms The interview tools found on pages C-28 through C-35 contain age-specific questions to guide the provider. Items of concern should be circled. Extensive notes may have to be made on a separate sheet. A copy of this form may be used as a referral form. The parent questionnaire is similar to the interview tool. It is advisable in the first visit to explain and administer the interview face-to-face. At subsequent visits, the age-appro CPT only copyright 2005 American Medical Association. All rights reserved.