TMPPM 2007 >43.1.7 Benefits and Limitations

43.1.7 Benefits and Limitations

43.1.7.1 Medical Check Up Visits

Medical check up services are covered for clients birth through 20 years of age when delivered in accordance with the THSteps Medical Check Ups Periodicity Schedule. The schedule specifies the screening procedures recom-mended at each stage of the client's life and identifies the time period based on the client's age when medical check up services are reimbursable.

Note: 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. All components of the check up must be completed if submitting a claim for a medical document.

Providers should treat each THSteps check up 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 check up should be completed according to the individual client's appropriate needs. If a component cannot be completed because of a medical contraindication of a client's condition, then a follow-up visit is necessary. The provider should document the reason the component(s) was not completed and schedule a follow-up visit.

If components of the THSteps check up have been provided one month preceding the client's birthday month and the medical check up 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 check up currently being billed.

All components of the THSteps medical check up are included in the reimbursement of the visit. The visit is a comprehensive medical check up and must include all assessments, screenings, immunizations, and laboratory tests as indicated on the periodicity schedule. When there is an available Current Procedural Terminology (CPT) code for a component, it is not reimbursed separately on the same day as a medical check up.

Reminder: A complete check up is an assessment provided in accordance with mandated procedures and the narrative standards outlined for each procedure. Incomplete medical check ups are not reimbursed.

Sports physical/examinations are not a benefit of the Texas Medicaid Program. If the client is due for a THSteps medical check up and a comprehensive medical check up is completed, a THSteps medical check up may be reimbursed.

Refer to: "THSteps Medical Check Ups Periodicity Schedule for Infants, Children, and Adolescents (Birth Through 20 Years of Age)" for information about the components required at specific ages.

In the first two years of the client's life, providers may bill up to nine visits, regardless of the date of the last medical check up.

All of the check ups 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 check up determines that a referral for diagnosis and treatment is necessary for a condition found during the check up, the referral should be made to a provider who is qualified to perform diagnostic or treatment services.

If the provider performing the medical check up can provide treatment for the identified condition, a separate claim for an established client office visit may be submitted on the same day as the check up with an appropriate established client CPT code for the diagnosis and treatment of the identified problem. Often minor illnesses or conditions (e.g., follow-up of a mild upper respiratory infection) during the THSteps medical check up do not warrant additional billing.

Exception: Medicaid Managed Care (including PCCM) clients must be referred to their designated primary care provider for further treatment or referral.

In addition, federal and state law requires providers to refer children within two business days of identification of a suspected developmental delay or disability to the local ECI program for children birth to 3 years. The provider may call the local ECI Program or the DARS Inquiries Line at 1-800-628-5115 to make referrals. Children 3 years and older with a suspected developmental delay or disability should be referred to the local school district.

For acute care claims, providers must bill the CPT codes for evaluation and management (E/M) of established clients with an appropriate diagnosis documented.