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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 : 5.3.11 Mandated Components : 5.3.11.1 Comprehensive Health and Developmental History

5.3.11.1
5.3.11.1.1
Dietary practices must be evaluated at each checkup to identify and address nutritional issues or concerns.
5.3.11.1.2
Developmental surveillance or screening is a required component of every checkup for clients who are birth through 6 years of age. Autism screening is required at 18 months of age and again at 24 months of age. If not completed at 24 months of age, or if there is a particular concern it should be completed at 30 months of age.
As THSteps medical services, developmental screening (procedure code 96110) and autism screening (procedure code 96110 with modifier U6) are limited to once per day, per client, by the same provider or provider group. This service will be denied unless a checkup, exception-to-periodicity checkup, or follow-up visit was reimbursed for the same date of service by the same provider.
Standardized developmental screening is required at the ages listed in the table below. Providers must use one of the validated, standardized tools listed below when performing a developmental or autism screening. A standardized screen is not required at other checkups up to and including the 6-year checkup; however, developmental surveillance is required at these checkups and includes a review of milestones (gross and fine motor skills, communication skills, speech-language development, self-help/care skills, and social, emotional, and cognitive development) and mental health and is not considered a separate service.
Providers may be reimbursed separately when using one of the required screening tools listed in the table below in addition to the checkup visit at specific age visits. THSteps requires one of the following required standardized tools at the following ages for a checkup to be considered complete:
 
Ages and Stages Questionnaire (ASQ) or Parents’ Evaluation of Development Status (PEDS)
Modified Checklist for Autism in Toddlers (M-CHAT) or M-CHAT Revised with Follow-Up (M-CHAT R/F)
ASQ, Ages and Stages Questionnaire: Social-Emotional (ASQ:SE) or PEDS
If a developmental or autism screening that is required in the Required Screening Ages and Recommended Tools table is not completed during a checkup or if the client is being seen for the first time, standardized developmental screening must be completed through 6 years of age.
If a provider administers a standardized and validated developmental screening at additional checkups other than those listed in the Required Screening Ages and Recommended Tools table, the provider must document the rationale for the additional screening, which may be due to provider or parental concerns.
Developmental screening that is completed without the use of one of the required standardized screening tools is not a separately payable benefit, and the checkup will be considered incomplete.
Standardized developmental screening as part of a medical checkup and for ages other than required on the periodicity schedule is not covered when completed for the sole purpose of meeting day care, Head Start, or school program requirements.
Standardized developmental screening may be performed outside a THSteps medical checkup as part of development and neurological assessment testing.
Refer to:
Subsection 9.2.25, “Developmental and Neurological Assessment and Testing” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2 Provider Handbooks) for information related to developmental screening testing outside a THSteps medical checkup.
Referral for an in-depth developmental evaluation is determined by the criteria of the specific tool or at the provider’s discretion. Referral for in-depth evaluation of development should be provided when parents express concern about their child’s development, regardless of scoring on a standardized development screening tool. A medical diagnosis or a confirmed developmental delay is not required for referrals.
The ECI program serves clients who are birth through 35 months of age with disabilities or developmental delays. Under federal and state regulations, all health-care professionals are required to refer children to the Texas ECI program as soon as possible, but no longer than 7 days after identifying a disability or a suspected delay in development, even if referred to an appropriate provider for further testing. If the client is 3 years of age or older, referral should be made to the local school district’s special education program.
5.3.11.1.3
Mental health screening for behavioral, social, and emotional development is required at each THSteps checkup.
Mental health screening using one of the following validated, standardized mental health screening tools recognized by THSteps is required once for all clients who are 12 through 18 years of age:
A mental health screening must be submitted with procedure code 99420. When claims with procedure code 99420 are submitted for mental health screenings, one of the validated, standardized mental health screening tools recognized by THSteps must be used.
Mental health screening at other checkups does not require the use of a validated, standardized mental health screening tool.
Procedure code 99420 must be submitted on the same date of service by the same provider as procedure code 99384, 99385, 99394, or 99395, and reimbursement is limited to once per lifetime.
The client’s medical record must include documentation identifying the tool that was used, the screening results, and any referrals that are made.
When the clinician conducting the mental health screen has the appropriate training and credentials to conduct the mental health evaluation and provide treatment, the clinician may choose to provide the mental health services or refer the client to an appropriate clinician. Clinicians who do not have these qualifications must refer clients to a qualified Medicaid-enrolled mental health specialist for such care.
For additional information about conducting a mental health screen, providers can refer to the THSteps online educational module “Mental Health Screening” at www.txhealthsteps.com.
5.3.11.1.4
Administer the TB risk screening tool annually beginning at 12 months of age and thereafter at other medical checkups.
The TB risk screening tool is available on the DSHS website at www.dshs.state.tx.us/thsteps/forms.shtm.
A TST is to be administered when the screening tool indicates a risk for possible exposure. Providers must use procedure code 86580 when a TST is administered.
A TST may be reimbursed separately when performed as part of a THSteps medical checkup. TB screenings are part of the encounter rates for FQHCs and RHCs and are not reimbursed separately.
A follow-up visit (procedure code 99211) is required to read all TSTs. The provider may bill the follow-up visit with a provider identifier and THSteps benefit code.
If further evaluation is required to diagnose either latent TB infection or active TB disease, the provider may bill the appropriate E/M office visit code. Diagnosis and treatment are provided as a medical office visit. Providers can also call the TB program at 1-512-533-3000 for additional clinical information.
Refer to:
“TB Policies and Procedures” at www.dshs.state.tx.us/idcu/disease/tb/ for guidance on skin testing children in various settings. Click TB Control Standards, and then look under “Texas TB Policies and Procedures.”

Texas Medicaid & Healthcare Partnership
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