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43.1.7.5 Exceptions to Periodicity
Payment is made for medical check ups that are exceptions to the periodicity schedule to allow for services in the categories below; however, if the client is due for a medical check up then the visit should be billed as regular check up, not an exception to periodicity.
• 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, pre-adoption, or to provide a check up prior to the next periodically due check up, if the client will not be available when due. This includes clients whose parents are migrant/seasonal workers.
•Required for dental services provided under general anesthesia.
•Medically necessary check up in the first six days of life.
Refer to: "CMS-1500 Claim Filing Instructions" 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 check up. Additionally, providers must use modifiers 23, 32, and SC to indicate the exception.
•Modifier 23 refers to a client who receives a medical check up prior to general anesthesia related to dental procedures.
•Modifier 32 refers to a client who receives a medical check up as mandated by state or federal programs, such as Head Start, entry into foster care, or adoption.
•Modifier SC refers to a check up that a client is receiving as a medically necessary service.
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