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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 5. THSteps Medical : 5.3 Services, Benefits, Limitations, and Prior Authorization : 5.3.9 Mandated Components : 5.3.9.6 Laboratory Test

5.3.9.6
The complete medical checkup may include laboratory testing. The periodicity schedule indicates which age-appropriate checkups require laboratory screening. The DSHS Laboratory provides supplies for specimen collection and mailing and shipping; and reporting of test results to enrolled THSteps medical providers that submit specimens to the DSHS Laboratory. These services and supplies are limited to THSteps medical checkup laboratory services provided in the course of a medical checkup to THSteps clients. Unauthorized use of services and supplies is a violation of federal regulations.
DSHS laboratory services are available at no cost to all enrolled THSteps medical providers for THSteps medical checkups only. THSteps laboratory services provided by a private laboratory and a medical provider are not reimbursed.
Example:
If a provider needs immediate results for the anemia screening, the specimen may be processed in the office/clinic, and the test results must be documented in the client's medical record but the provider will not be reimbursed.
Exception:
For tests related to screening for type 2 diabetes, hyperlipidemia, HIV, and syphilis, the client or specimen may be sent to the laboratory of the provider's choice. Point-of-care testing for the initial blood lead screening may be performed in the provider's office.
Documented laboratory test results obtained within the preceding 30 days for clients 2 years of age or younger, and 90 days for 3 years of age or older, may be used to meet the laboratory testing requirement and must include:
The date of service for the laboratory testing is to be the date the specimen was obtained as part of the medical checkup, follow-up visit, or exception-to-periodicity visit.
The procedure codes for any laboratory testing services other than screening for type 2 diabetes, hyperlipidemia, HIV, and syphilis are informational when obtained on the same day a checkup is completed, even if an acute care visit is performed on the same date of service.
If the laboratory testing as identified on the THSteps Medical Checkup Periodicity Schedule is obtained as part of an E/M visit on a different date of service than a checkup, the services may be considered as separate services and may be sent to the laboratory of the provider's choice.
Laboratory specimens obtained for diagnostic evaluation, rather than for screening purposes and performed on the same day as a checkup, may be considered as separate services unless the test is required as part of a checkup. If the test is required as part of the checkup, the laboratory specimens, with the exception of screening tests for hyperlipidemia, type 2 diabetes, HIV, and syphilis must be submitted to the DSHS Laboratory for testing. Diagnostic specimens that are not part of the checkup can be sent to the laboratory of the provider's choice.
Laboratory services that are related to a THSteps medical checkup 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 checkup.
Providers can refer to the laboratory test procedure codes table below for tests listed on the THSteps Periodicity Schedule that are available from the DSHS Laboratory. Tests that are required to be sent to a DSHS laboratory but are processed elsewhere are not reimbursed; however, the documentation results may be used to meet the requirements for a checkup.
The following procedure codes may not be billed separately with an office visit or consultation on the same day as a THSteps medical checkup 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 checkup are denied and are subject to retrospective review:
For specimens sent to the DSHS Laboratory, the checkup includes the specimen collection and supplies, mailing and shipping supplies, and the review of the test results from the DSHS laboratory.
For specimens sent to a laboratory of the provider's choice, the checkup includes the specimen collection or ordering of the test and the review of the test results from the laboratory.
5.3.9.6.1 Laboratory Supplies
The DSHS Laboratory verifies enrollment of THSteps medical providers before sending laboratory supplies and the informational packet to the medical providers. Newly enrolled providers should contact the DSHS Laboratory to request laboratory supplies. Upon request, the DSHS Laboratory provides THSteps medical providers with laboratory supplies associated with specimen collection, submission, and mailing and shipping of required laboratory tests related to medical checkups. Requests for specimen submission forms are routed to the DSHS Laboratory reporting staff and mailed separately to the providers. The Child Health Laboratory Supplies Order Form lists the laboratory supplies that the DSHS Laboratory provides to THSteps medical providers.
To obtain a THSteps Child Health Laboratory Supplies Order Form, providers can call (512) 776-7661 or 1-888-963-7111, ext. 7661, or download the form online at www.dshs.state.tx.us/lab/MRS_forms.shtm.
5.3.9.6.2 Newborn Screening Supplies
Providers that perform newborn screening (NBS) can order supplies by submitting a Newborn Screening Supplies Order Form to the DSHS Laboratory. The Newborn Screening Supplies Order Form lists the NBS supplies that the DSHS Laboratory provides to medical providers.
Note:
For newborn screening, only the specimen collection form (NBS 3), mailing envelope and provider address labels are provided. Lancets, mailing, and shipping costs are the responsibility of the submitter.
To obtain a Newborn Screening Supplies Order Form, medical providers can call (512) 776-7661 or
1-888-963-7111, ext. 7661, or download the form online at www.dshs.state.tx.us/lab/MRS_forms.shtm.
Contact information for requesting laboratory supplies:
Container Preparation
Laboratory Services Section, MC 1947
Department of State Health Services
PO Box 149347
Austin, TX 78714-93471
(512) 776-7661 or 1-888-963-7111, Ext. 7661
Fax: (512) 776-7672
5.3.9.6.3 Laboratory Submission
All required laboratory testing for THSteps clients must be performed by the Department of State Health Services (DSHS) Laboratory in Austin, TX, with the following exceptions:
Specimens collected for type 2 diabetes, hyperlipidemia, HIV, and syphilis screening may be sent to the laboratory of a provider's choice or to the DSHS Laboratory in Austin if submission requirements can be met.
Specimens for gonorrhea and Chlamydia screening are processed by the Women's Health Laboratories (WHL) in San Antonio, TX. Information regarding collection, handling, and submission of these specimens is available from the WHL.
THSteps medical checkup laboratory specimens submitted to the DSHS Laboratory must be accompanied with the DSHS Laboratory Specimen Submission Form (Newborn Screening NBS 3 or G-THSTEPS as appropriate) for test(s) requested. All forms must include the client's name and Medicaid number as they appear on the Your Texas Benefits card. 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), providers must write “pending” in the Medicaid number space, which is located in the payor source section of the laboratory specimen submission form.
Laboratory specimens received at the DSHS Laboratory without a Medicaid number or the word “pending” written on the accompanying specimen submission form will be analyzed, and the provider will be billed.
Specimens submitted to the laboratory must also meet specific acceptance criteria. For additional information on specimen submission, providers can refer to the DSHS Laboratory web page at: www.dshs.state.tx.us/lab/MRS_specimens.shtm.
Note:
If an extreme health problem exists and telephone results are needed quickly, providers should make a request on the laboratory form. 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 test results (e.g., hemoglobin equal to or below 7g/dL or blood lead levels 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.
The THSteps laboratory specimens that can be mailed at ambient temperature can be sent to the DSHS Laboratory Services Section through the U.S. Postal Service at no cost using the provided business reply labels:
DSHS Laboratory Services Section
Walter Douglass
PO Box 149163
Austin, TX 78714-9803
(512) 776-7318 or 1-888-963-7111 Ext. 7318
THSteps laboratory specimens that require overnight shipping on cold packs through a courier service must be sent to the DSHS Laboratory Services Section at:
DSHS Laboratory Services Section, MC-1947
1100 West 49th Street
Austin, TX 78756-3199
Newborn Screening specimens can be sent through the U.S. Postal Service to:
Texas Department of State Health Services
Laboratory Services Section
PO Box 149341
Austin, TX 78714-9341
Gonorrhea and Chlamydia specimens are sent to:
Women's Health Laboratories (WHL)
2303 SE Military Drive, Suite 1
San Antonio, TX 78223
Customer Service: 1-888-440-5002 or (210) 531-4596
Fax: (210) 531-4506
www.dshs.state.tx.us/lab/whl.shtm
Contact WHL for questions about submission requirements such as collection, supplies, and mailing of specimens for THSteps gonorrhea and Chlamydia adolescent screening.
5.3.9.6.4 Send Comments
Providers with comments or feedback about THSteps specimen collection supplies should contact the DSHS Laboratory. Supplies are evaluated continually, and feedback from supply users is useful. Documented comments may support, justify, or initiate a change in a provided item. Providers can send a brief letter or fax to the following address:
Quality Assurance Unit
Laboratory Services Section, MC 1947
Department of State Health Services
PO Box 149347
Austin, TX 78714-9347
Fax: (512) 776-7294
5.3.9.6.5 Laboratory Reporting
A computer-generated result report is mailed or faxed to the submitting THSteps medical checkup provider. A statistical report is mailed quarterly to providers documenting their total number of submissions by diagnosis and adequacy. The DSHS Laboratory has web-based services (remote order and result reporting) available for THSteps and Newborn Screening laboratory services. For more information, providers can visit the DSHS website at www.dshs.state.tx.us/lab/remoteData.shtm or call 1‑888‑963‑7111, Ext. 6030.
5.3.9.6.6 Required Laboratory Tests Related to Medical Checkups
The following laboratory screening procedures are required components of the THSteps medical checkup and are to be performed in accordance with the age and frequency specified on the THSteps medical checkup periodicity schedule. Due to changes in specimen collection, handling, and submission criteria, providers should contact the DSHS Laboratory for the most current specimen requirements by calling 1-888-963-7111, Ext. 7430 or visiting the DSHS website at www.dshs.state.tx.us/lab/MRS_labtests_toc.shtm.
Anemia Screening
Anemia screening by hemoglobin or hematocrit levels is required at ages as noted on the THSteps Periodicity Schedule. These tests may be completed in a provider's office or clinic if there is an urgent need for test results, but will not be reimbursed separately. These test results must be documented in the client's medical record.
Lead Screening and Testing
In accordance with current federal regulations, THSteps requires blood lead screening at ages notated on the THSteps Periodicity Schedule and must be performed during the medical checkup.
Environmental lead risk may be addressed at other visits using the Lead Risk Questionnaire, Form Pb-110, which is provided in both English and Spanish at www.dshs.state.tx.us/thsteps/forms.shtm. Providers may use an equivalent form of their choice.
The initial lead testing may be performed using a venous or capillary specimen, and must either be sent to the DSHS lab or performed in the provider's office using point-of-care testing. If the client has an elevated blood lead level of 10mcg/dL or greater, the provider must perform a confirmatory test using a venous specimen. The confirmatory specimen may be sent to the DSHS lab, or the client or specimen may be sent to a lab of the provider's choice.
All blood lead levels in clients who are 14 years of age or younger must be reported to DSHS. Reports should include all information as required on the Texas Child Blood Lead Level Report Form, F09-11709, which can be found at www.dshs.state.tx.us/lead/providers.shtm or by calling 1-800-588-1248.
Elevated blood lead levels for clients who are 15 years of age or older must be reported to DSHS and should include all information required on the Adult Blood Lead Report Form F09-11624.
Point-of-care lead testing (procedure code 83655 with modifier QW) may be reimbursed to THSteps medical providers when performed in the provider's office. Providers must have a CLIA certificate of waiver.
Blood lead testing is part of the encounter rates for FQHCs and RHCs and is not reimbursed separately.
Providers may obtain more information about the medical and environmental management of lead- poisoned children from the DSHS Childhood Lead Poisoning Prevention Program by calling
1-800-588-1248 or visiting the web page at www.dshs.state.tx.us/lead.
Refer to:
Appendix C: Lead Screening in this handbook for more information on lead screening procedures and follow-up.
Hyperlipidemia
Screening for hyperlipidemia is based on risk assessment. THSteps does not provide a formal risk assessment tool. Providers may refer to the AAP policy statement on cholesterol screening for more information. Specimens may be sent to the laboratory of the provider's choice, including the DSHS Laboratory.
Diabetes
Screening for type 2 diabetes is based on risk assessment. THSteps does not provide a formal risk assessment tool. Specimens may be sent to the laboratory of the provider's choice, including the DSHS Laboratory.
Newborn Screening
The initial newborn screen must be completed between 24 and 48 hours. The second newborn screen must be done between 1 and 2 weeks of age. For further information, access the Newborn Screening Program website at www.dshs.state.tx.us/newborn/default.shtm.
The mandated newborn screen repeated at one to two weeks of age is a required component of the THSteps medical checkup. Clients may not be referred to the local health department or other providers for this service.
Health and Safety Code, Chapter 33, Vernon's Texas Codes Annotated, requires testing for the disorders recommended by the American College of Medical Genetics (ACMG) on all newborns. This testing is the responsibility of any provider attending the newborn. If there is any doubt that a client younger than 12 months of age was properly tested, the provider should submit the blood sample on the appropriate DSHS Form NBS 3 to the DSHS Newborn Screening Laboratory.
Note:
The results are mailed to the address that the provider indicated on Form NBS 3. Recommendations for necessary follow-up procedures are included with the report. The NBS Clinical Care Coordination (Case Management) staff will contact providers when there are significant abnormalities.
5.3.9.6.7 Additional Required Laboratory Tests Related to Medical Checkups for Adolescents
The following is a list of required and risk-based laboratory tests related to medical checkups for adolescents and guidelines for testing for sexually transmitted diseases (STDs).
Testing for Sexually Transmitted Diseases
Syphilis Testing
Syphilis testing should be performed on adolescents that are at high risk for infection. Specimens may be sent to the laboratory of the provider's choice, including the DSHS Laboratory.
Gonorrhea and Chlamydia Infection Testing
Testing for gonorrhea and Chlamydia should be performed on adolescents that are at high risk for infection. Specimens must be sent to the Women’s Health Lab in San Antonio.
HIV Testing
It is critical to maintain confidentiality when caring for clients, as well as their specimens. Testing should be performed only after informed consent is obtained from the adolescent. Informed consent does not have to be written as long as there is documentation in the medical record that the test has been explained and consent has been obtained. Specimens may be sent to the laboratory of the provider's choice, including the DSHS Laboratory.
The CDC guidelines state that routine HIV screening should occur for everyone between 13 and 64 years of age. HIV testing is not required at these ages, but the offer should be made beginning at 13 years of age and, if not performed at that time, should be offered at subsequent ages according to risk.
HIV testing may be performed for adolescents without requirement of parental consent. Adolescents at risk for HIV infection should be offered confidential HIV screening. If the client refuses the HIV test, the provider may not perform the test and must explain the option of anonymous testing and refer the client to a testing facility that offers anonymous testing. A notation must be made in the medical record that notification of the HIV test and the right to refuse was given. Providers may call the HIV/STD InfoLine for referrals to HIV/AIDS testing sites; prevention, case management, and treatment providers; STD clinics; and other related service organizations. The HIV/STD InfoLine is 1-800-299-2437. This toll-free HIV/Acquired Immunodeficiency Syndrome (AIDS) and STD information and referral service is available for English- and Spanish-speaking callers and for those who are hearing-impaired.
Communicable Disease Reporting
Diagnoses of sexually transmitted diseases (STDs), including HIV, are reportable conditions under 25 TAC, Chapter 97. Providers must report confirmed diagnoses of STDs as required by 25 TAC §97.132.

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