TMPPM 2008 > Texas Medicaid Services > Texas Health Steps (THSteps) > Check Up Laboratory Procedures

43.3.2 Laboratory Services

Laboratory services are available from the DSHS laboratory and may not be billed separately with an office visit or consultation on the same day as a THSteps medical check up.

Claims for THSteps check ups and for laboratory services are subject to retrospective review to assure compliance with the policy.

A THSteps laboratory test included in the periodicity schedule for a specific visit (or needed if not obtained at a previous visit) is a required component of the visit. These laboratory specimens, except Pap smears, screening for hyperlipidemia, and type 2 diabetes, must be submitted to the DSHS laboratory. Pap smears must be sent to the Women's Health Laboratory in San Antonio. Screening for hyperlipidemia and Type 2 diabetes may be sent to a laboratory of the provider's choice including DSHS laboratory.

Refer to: "Texas Health Steps (THSteps) Outpatient Laboratory Services" for the addresses of the laboratories.

Providers can refer to the table at the end of this section for a list of the tests available from the DSHS laboratory that are included in the periodicity schedule. It is permissible to complete hematocrit and hemoglobin testing on site; however, there is no separate reimbursement for these tests and results must be clearly documented in the medical record. Results from these two tests are also acceptable from a WIC clinic or other provider, if actual results are available and have been obtained within one month of the visit date.

The THSteps program requires that all laboratory tests noted on the periodicity schedule be obtained as part of the medical check up, so all providers must use the date of the medical check up as the date of laboratory service.

If the medical check up findings result in an E/M visit for an acute problem, the provider should complete the test necessary to make a diagnosis. Tests obtained as part of the E/M visit may be processed at the provider's laboratory of choice and may be billed unless the test is a required component of the THSteps visit on the same day of a THSteps medical check up.

Note: Providers should make a request on the laboratory form if an extreme health problem exists and telephone results are needed quickly. With the exception of weekends and holidays, routine specimens are analyzed and reported within three business days after receipt by the DSHS laboratory. Critical abnormal tests results (e.g., hemoglobin equal to or below 7g/dL or blood lead level greater than or equal to 40 mcg/dL) are identified in the laboratory within 36 hours after receipt of specimens and are reported to the submitter by telephone within one hour of confirmation.

THSteps laboratory specimens submitted to DSHS must include the client's name and Medicaid number as they appear on the Medicaid Identification (Form H3087) on a DSHS laboratory Request Form (Newborn Screening NBS-3, G-1B, G-2A, G-2B). Providers must write "pending" in the Medicaid number space, which is located in the payor source section of the laboratory requisition form, if a number is not currently available but is pending (i.e., a newborn or a newly-certified client verified by a Medicaid Eligibility Verification (Form H1027) as eligible for Medicaid).

Laboratory specimens received at DSHS that do not have a Medicaid number or the word pending written in the nine-character space for the Medicaid number will be analyzed, and the provider will be billed. Laboratory tests must also meet specific acceptance criteria for specimens submitted. For further information on specimen submission, providers can refer to the DSHS laboratory web page at www.dshs.state.tx.us/lab/MRS_specimens.shtm.

The reimbursement for the complete medical check up includes specimen collection, shipping, testing, and receiving test results from the DSHS laboratory.

The following services may not be billed separately with an office visit or consultation on the same day as a THSteps medical check up either by a provider or laboratory. Claims for procedure codes listed below submitted by a provider or a commercial laboratory for the same DOS as a THSteps medical check up are denied and are subject to retrospective review:

The following are laboratory specimens related to blood testing screening for hyperlipidemia or Type 2 diabetes that may be sent to a laboratory of the provider's choice.

Laboratories billing for these procedure codes on the same date of service as a medical check up visit may be reimbursed separately.

Providers who obtain and process these specimens in-house are not reimbursed separately.