TMPPM 2011 > Children's Services Handbook > THSteps Medical > Services/Benefits, Limitations, and Prior Authorization > THSteps Medical Checkups

5.3 Services/Benefits, Limitations, and Prior Authorization

5.3.1 THSteps Medical Checkups

THSteps medical checkups reflect the federal and state requirements for a preventative checkup. Preventive care medical checkups are a benefit of the THSteps program if they are provided by enrolled THSteps providers and all of the required components are completed. An incomplete periodic medical checkup is not a benefit. The THSteps periodicity schedule specifies screening procedures required at each stage of the client's life to ensure that health screenings occur at age-appropriate points in a client's life.

To receive services, the client must be eligible to receive Medicaid services and must be birth through 20 years of age at the time services are delivered. When a client turns 21 years of age after the first of a month, the client remains eligible for a checkup through the end of that month.

Components of a medical checkup that have an available CPT code are not reimbursed separately on the same day as a medical checkup, with the exception of developmental and autism screening.

Reminder: Incomplete medical checkups are subject to recoupment unless there is documentation supporting why a component was not completed.

Sports physical examinations are not a benefit of Texas Medicaid. If the client is due for a THSteps medical checkup and a comprehensive medical checkup is completed, a THSteps medical checkup may be reimbursed and the provider may complete the documentation for the sports physical.

Refer to: Subsection 5.3.1.9, "THSteps Medical Checkups Periodicity Schedule" in this handbook for information about the components required at specific ages.

Checkups should be scheduled, to the extent possible, based on the ages on the periodicity schedule to accommodate the need for flexibility when scheduling checkup appointments. A periodic age range is available with 11 billable visits possible in the first two years of the client's life.

The following table lists the number of visits allowed at each age range:

All of the checkups listed on the periodicity schedule were developed according to the recommendations of the AAP and in consultation with recognized authorities in pediatric preventive health. In Texas, THSteps has modified the AAP periodicity schedule based on the scheduling of laboratory or other tests in federal EPSDT or state regulations.

If the provider that performs the medical checkup provides treatment for an identified condition on the same day, the provider may submit a separate claim for an acute care established-client office visit. The separate claim must include the established-client procedure code that is appropriate for the diagnosis and treatment of the identified problem. Treatment of minor illnesses or conditions (e.g., follow-up of a mild upper respiratory infection) during the THSteps medical checkup may not warrant additional billing.

Medicaid managed care (including PCCM) clients must be referred to their designated primary care provider for further treatment or referral if they are receiving a THSteps checkup outside the medical home.

For more information about conducting a THSteps checkup, providers can refer to the THSteps online educational modules at www.txhealthsteps.com.