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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 5 THSteps Medical : 5.4 Documentation Requirements

5.4
All THSteps services require documentation to support the medical necessity of the services rendered including THSteps medical services. THSteps services are subject to retrospective review and recoupment if documentation does not support the services billed.
The following federal and state mandated components must be documented in the client’s medical record for the checkup to be considered complete:
The client’s medical record must include documentation to support the rationale a component was not completed, and a plan to complete the component(s) if not due to parent or caregiver concern or reasons of conscience, including religious beliefs.

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