TMPPM 2011 >5.3.1.6 Exception-to-Periodicity Checkups

Exception-to-periodicity checkups are complete medical checkups completed outside the timeframes listed in the THSteps Periodicity Schedule due to extenuating circumstances. A THSteps medical checkup is allowed outside of the regular THSteps Periodicity Schedule (exception to periodicity) when:

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Medically necessary, for example, for a client with developmental delay, suspected abuse, or other medical concerns or a client in a high-risk environment, such as living with a sibling with elevated blood lead.

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Required to meet state or federal exam requirements for Head Start, day care, foster care, or preadoption.

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The provider is aware that the client is not due for a checkup, the visit must be submitted as an exception to periodicity.

Note: A sports physical is not a reason for an exception-to-periodicity checkup.

When billing for an exception-to-periodicity visit, provider must also include the most appropriate exception-to-periodicity modifiers. Claims for periodic THSteps medical checkups exceeding periodicity that do not include one for these modifiers will be denied as exceeding periodicity.


Modifier	Description
SC	Medically necessary service or supply
23	Unusual Anesthesia: Occasionally, a procedure that usually requires either no anesthesia or local anesthesia must be done under general anesthesia because of unusual circumstances. This circumstance may be reported by adding the modifier "-23" to the procedure code of the basic service or by use of the separate 5-digit modifier code 09923.
32	Mandated Services: Services related to mandated consultation or related services (e.g., PRO, third party payer, governmental, legislative, or regulatory requirement) may be identified by adding the modifier "-32" to the basic procedure or the service may be reported by use of the 5-digit modifier code 09932.

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 23, 32, and SC to indicate the exception.