Clients who are birth through 20 years of age may receive medical checkups in accordance with the THSteps Periodicity Schedule. The THSteps Periodicity Schedule recommends 11 checkups for clients birth through 2 years of age and annually for clients from 3 through 20 years of age. The provider must offer checkups according to the THSteps Periodicity Schedule. Click here to view the revised THSteps Periodicity Schedule .

Four new checkups have been added to the THSteps Periodicity Schedule for the following ages:

New Required Checkup Ages
3 to 5 days old	30 months of age	7 years of age	9 years of age

Providers should schedule checkups to conform as closely as possible to the ages on the periodicity schedule while allowing flexibility to accommodate the needs of clients and parents or caregivers.

Developmental Screening

Procedure code S-96110, as a THSteps medical service, is limited to once per day per client by the same provider or provider group and will be denied unless submitted by the same provider or provider group for the same date of service as a checkup, exception-to-periodicity checkup, or follow-up visit.

For clients 9 months through 4 years of age, the medical checkups must include the standardized developmental screenings detailed in the following table. Provider must use a standardized tool when performing a developmental screening (procedure code S‑96110) or autism screening (procedure code S-96110 with modifier U6). Providers may be reimbursed for the screens in addition to the checkup visit. THSteps accepts the following standardized tools that are required at the following ages:

 

Required Screening Ages and Tools
Screening Ages	Developmental Screening Tools	Autism Screening Tools
9 months	Ages and Stages Questionnaire (ASQ)or Parents’ Evaluation of Developmental Status (PEDS)
1 year	ASQ or PEDS (if not completed at 9 months or with provider/parental concern)
18 months	ASQ or PEDS	Modified Checklist for Autism for Toddlers (MCHAT)
24 months	ASQ or PEDS
30 months	ASQ or PEDS (if not completed at 24 months or with provider/parental concern)
3 years	ASQ, Ages and Stages Questionnaire-SE (ASQ-SE), or PEDS
4 years	ASQ, ASQ-SE, or PEDS

 

Through August 31, 2011, providers may choose to use a standardized screening tool that is not listed in the Required Screening Ages and Tools table to complete the requirements of a medical checkup visit; however, providers may not submit a claim for a tool that is not listed in the table. If a standardized screen that is not listed is billed, it will be subject to recoupment.

A standardized developmental screen is not required at other checkups for a client birth through 6 years of age; however, a review of milestones and mental health is required and is not considered as a separate service.

If a developmental or autism screening that is required in the Required Screening Ages and Tools table is missed, the provider must complete the missed standardized screening at the next checkup.

The provider must also complete a standardized screening when seeing a client who is 6 months through 6 years of age for the first time.

If a provider administers a standardized developmental screening at additional checkups other than those listed in the Required Screening Ages and Tools table, the provider must document the rationale for the additional screening, which may be due to provider or parental concerns.

Standardized developmental screening (procedure code S/5-96110) is not covered when it is completed to meet daycare, Head Start, or school program requirements unless the screening is completed during an acute care visit in a clinical setting.

Developmental screening that is completed without the use of one of the recommended standardized screening tools is not a separately payable benefit.

Developmental screening that is performed outside of a THSteps medical checkup may be a benefit when medically necessary and is limited to once per rolling year, any provider.

Administration of the Mini Mental State Examination (MMSE) is considered part of an evaluation and management (E/M) service and is not separately reimbursed.

Checkups

With the exception of standardized developmental screening, providers will not be reimbursed separately for individual components of a required checkup.

A checkup and the associated follow-up visit may not be reimbursed on the same date of service.

A new patient is one who has not received any professional services within the preceding 3 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 codes S-99381, S-99382, S-99383, S-99384, and S-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 will be 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 after the new patient THSteps checkup continues the established relationship with the provider.

If a new patient checkup has been billed within the preceding three years, subsequent checkups and acute care visits billed as new patient services will be denied when billed by the same provider or provider group.

For a client that is a new patient, an acute care and checkup visit may be reimbursed on the same date of service by the same provider or group. The checkup visit must be billed as a new patient checkup and the acute care visit as an established visit.

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 submitted 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.

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.

For more information, call the TMHP Contact Center at 1-800-925-9126.