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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 5 THSteps Medical : 5.3 Services, Benefits, Limitations, and Prior Authorization : 5.3.6 THSteps Medical Checkups

THSteps medical checkups reflect the federal and state requirements for a preventive checkup. Preventive care medical checkups are a benefit of the THSteps program if they are provided by enrolled THSteps providers and all of the required components are completed. An incomplete preventive medical checkup is not a benefit. The THSteps periodicity schedule specifies screening procedures required at each stage of the client’s life to ensure that health screenings occur at age-appropriate points in a client’s life.
Components of a medical checkup that have an available CPT code are not reimbursed separately on the same day as a medical checkup, with the exception of initial point-of-care blood lead testing, once per lifetime mental health screening for adolescents, a tuberculin skin test (TST), developmental and autism screening, vaccine administration, and OEFV.
Refer to:
Subsection, “Mental Health Screening” in this handbook for more information about required mental health screenings.
Sports physical examinations are not a benefit of Texas Medicaid. If the client is due for a THSteps medical checkup and a comprehensive medical checkup is completed, a THSteps medical checkup may be reimbursed and the provider may complete the documentation for the sports physical.
THSteps preventive medical checkups are not a benefit under telemedicine or telehealth.
Refer to:
Checkups should be scheduled, to the extent possible, based on the ages on the periodicity schedule to accommodate the need for flexibility when scheduling checkup appointments.
The following table lists the number of visits allowed at each age range:
All of the checkups listed on the periodicity schedule were developed according to the recommendations of the AAP and in consultation with recognized authorities in pediatric preventive health. In Texas, the THSteps periodicity schedule may differ from the AAP periodicity schedule based on the scheduling of laboratory or other tests in federal EPSDT or state regulations.
For more information about conducting a THSteps checkup, providers can refer to the THSteps online educational modules at
The following table includes the procedure codes for checkups and the referral and condition indicators. Condition indicators must be used to describe the results of a checkup. A condition indicator must be submitted on the claim with the periodic medical checkup procedure code. Indicators are required whether a referral was made or not. If a referral is made, then providers must use the Y referral indicator. If no referral is made, then providers must use the N referral indicator.
99381, 99382, 99383, 99384, and 99385 (new client preventive visit)
99391, 99392, 99393, 99394, and 99395 (Established client preventive visit)
99381, 99382, 99383, 99384, and 99385 (new client preventive visit)
99391, 99392, 99393, 99394, and 99395 (established client preventive visit)
S2 (under treatment) or ST* (new services requested)
Y (yes THSteps or EPSDT referral was given to the client)
* The ST condition indicator should only be used when a referral is made to another provider or the client must be rescheduled for another appointment with the same provider. It does not include treatment initiated at the time of the checkup.
THSteps preventive care medical checkups for clients who are 18 through 20 years of age must be submitted with procedure codes 99385 or 99395 and diagnosis code Z0000 or Z0001.
Claims for procedure codes 99381, 99382, 99383, 99384, 99391, 99392, 99393, and 99394 must be submitted with the appropriate age related diagnosis code listed in the table below:
The age-appropriate diagnosis code for a preventive care medical checkup must be submitted on the claim. If an immunization is administered as part of the preventive care medical checkup, diagnosis code Z23 may also be included on the claim, in addition to the age-appropriate diagnosis.
If an immunization is the only service provided during an office visit, providers may submit only diagnosis code Z23 on the claim.
Modifier AM, SA, TD, or U7 must be submitted with the THSteps medical checkups procedure code to indicate the practitioner who performed the unclothed physical examination during the medical checkup.
THSteps medical checkups performed in an FQHC or RHC setting are paid an all-inclusive rate per encounter, which includes immunizations, developmental screening, autism screening, once per lifetime mental health screening for adolescents, TST, blood lead test, and oral evaluation and fluoride varnish. When submitting claims for THSteps checkups and services, RHC providers must use the national POS code 72, and FQHC providers must use modifier EP in addition to the modifiers used to identify who performed the medical checkup. In accordance with the federal rules for RHCs and FQHCs, an RN in an RHC or FQHC may not perform THSteps checkups independently of a physician’s interactions with the client.
Refer to:
Section 4, “Federally Qualified Health Center (FQHC)” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information related to billing.
Section 7, “Rural Health Clinic” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information related to billing.
Checkups, exception-to-periodicity checkups, and follow-up visits are limited to once per day any provider.
A checkup and the associated follow-up visit may not be reimbursed on the same date of service. The follow-up visit will be denied.
An incomplete checkup is subject to recoupment unless there is documentation to support why the component was not completed as part of the checkup.
A new patient is one who has not received any professional services within the preceding three years from the provider or from another provider of the same specialty who belongs to the same group practice. As an exception, a new preventive care medical checkup (procedure code 99381, 99382, 99383, 99384, or 99385) may be billed when no prior checkups have been billed by the same provider or provider group, even if an acute care new patient E/M service was previously performed by the same provider.
An additional new checkup is allowed only when the client has not received any professional services in the preceding three years from the same provider or another provider who belongs to the same group practice, because subsequent acute care visits to the new patient THSteps checkup continues the established relationship with the provider.
If the provider that performs the medical checkup provides treatment for an identified condition on the same day, the provider may submit a separate claim for an acute care established-client office visit. The separate claim must include the established-client procedure code that is appropriate for the diagnosis and treatment of the identified problem. Treatment of minor illnesses or conditions (e.g., follow-up of a mild upper respiratory infection) during the THSteps medical checkup may not warrant additional billing.
Acute Care Visits
When a new patient checkup is billed for the same date of service as a new patient acute care visit, both new patient services may be reimbursed when billed by the same provider or provider group if no other acute care visits or preventive care medical checkups have been billed in the past three years.
Providers must use modifier 25 to describe circumstances in which an acute care E/M visit was provided at the same time as a checkup. Providers must submit modifier 25 with the E/M procedure code when the rendered services are distinct and provided for a different diagnosis. Providers must bill an appropriate level E/M procedure code with the diagnosis that supports the acute care visit. The medical record must contain documentation that supports the medical necessity and the level of service of the E/M procedure code that is submitted for reimbursement.
An acute care E/M visit for an insignificant or trivial problem or abnormality billed on the same date of service as a checkup or exception-to-periodicity checkup is subject to recoupment.
Providers must bill an acute care visit with their provider identifier on a separate claim without benefit code EP1.
Refer to:
THSteps Preventive Visit Checkup with Immunization and Vaccine Administration on the TMHP website at for a claim form example.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.