Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Note: The Texas Health and Human Services Commission (HHSC) has requested that TMHP publish the following information.
Effective May 7, 2020, Texas Health Steps is distributing the following checkup guidelines for providers during the COVID-19 response.
Texas Health Steps Checkups
Texas Health Steps medical checkups require the following federally mandated components:
- Comprehensive health and developmental history, including physical and mental health and development
- Comprehensive unclothed physical examination
- Immunizations appropriate for age and health history
- Laboratory tests appropriate to age and risk, including lead toxicity screening
- Health education, including anticipatory guidance
To allow for continued provision of Texas Health Steps checkups during the period of social distancing due to COVID-19, HHSC is allowing remote delivery of certain components of medical checkups for children over 24 months of age (i.e. starting after the “24 month” checkup). Because some of these requirements (like immunizations and physical exams) require an in-person visit, providers must follow-up with their patients to ensure completion of any components within 6 months of the telemedicine visit.
Telemedicine or telephone-only delivery of Texas Health Steps checkups for children birth through 24 months of age (i.e. from the first newborn checkup through the “24 month” checkup) is not permitted.
Providers should use their clinical judgement to determine the appropriate components of the checkup for telemedicine (audio and visual) or telephone-only delivery. Audio and visual delivery is preferred over telephone-only delivery.
Physicians, including Doctors of Medicine (MDs) and Doctors of Osteopathic Medicine (DOs), as well as nurse practitioners, physician assistants, and registered nurses may perform remote delivery of these services. Non-physician provider supervision and delegation rules and regulations still apply.
Providers should bill using the appropriate Texas Health Steps checkup codes for the initial visit as is currently required. Providers may also bill for “add-on” codes (e.g. developmental screening, mental health screening, etc.) as they normally would. Modifier 95 must be included on the claim form to indicate remote delivery. Provider documentation should include the components that were not completed during the initial checkup using “COVID-19” as the reason for an incomplete checkup.
When the patient is brought into the office within the 6-month timeframe to complete the outstanding components of the visit, providers should bill the Texas Health Steps follow-up visit code (99211). Reimbursement will be identical to current rates for Texas Health Steps checkup codes.
Acceptable reasons for which the 6-month timeframe might not be met include, but are not limited to, the following:
- Child moves (from one service delivery area into another)
- Child switches primary care providers
- Child changes product service lines (e.g. from STAR to STAR Kids)
- Child switches MCOs
- Child moves out of state
- Child dies
- Child loses eligibility
- It is still not safe in 6 months to conduct an in-person visit
Providers must document the reason the checkup was not completed.
Providers may also bill an acute care Evaluation and Management (E/M) code at the time of the initial telemedicine checkup or at the “6-month” follow-up visit. Modifier 25 must be submitted with the acute care E/M procedure code to signify the distinct service rendered. Providers must bill the acute care visit on a separate claim without benefit code EP1.
This guidance applies to both new and established patients and is applicable for members in both managed care and fee-for-service Medicaid.
Three-Day Medical Exam
The 3-Day medical exam required by statute for children entering Department of Family and Protective Services (DFPS) conservatorship, telemedicine or telephone-only delivery will not be permitted, regardless of age, with one notable exception.
Remote delivery is allowed if a youth requires quarantine or isolation at the time of removal due to COVID-19 exposure or because the youth is known to be infected with COVID-19. Telemedicine, telehealth, or telephone-only will be allowed in this circumstance to avoid the risk of transmission in a health care setting. Audio and visual delivery is preferred, although telephone-only delivery will be permitted when audio and visual is not possible. Documentation should detail the circumstances that necessitated remote delivery. Providers should include modifier 95 when submitting a claim.
Providers are encouraged to explore different ways of ensuring children over 2 years of age receive age-appropriate vaccines in a timely manner. Providers may find recommended strategies at the American Academy of Pediatrics (AAP) website to include curbside and drive-through immunization clinics. Providers can visit the AAP website for more information: www.aap.org/en-us/Pages/Default.aspx.
TMHP and MCOs will use routine auditing processes to monitor complete Texas Health Steps checkups as they do today and will not implement new processes specific to this COVID-19 telemedicine guidance.
Reminder: A patient’s home is not excluded as a Texas Health Steps site for service for medical checkups.
For more information, call the TMHP Contact Center at 800-925-9126.