Below is a summary of the federal and state mandated components of a Texas Health Steps medical checkup which must be documented in the medical record as a condition for provider reimbursement by Medicaid. For details regarding specific checkup and reimbursement requirements, please review the Texas Medicaid Provider Procedures Manual (TMPPM), Children’s Services Handbook. The Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents (birth through 20 years of age) is a guide for Texas Health Steps providers to understanding the age-appropriate requirements for each checkup. The periodicity schedule is found on the Provider Information page of this website.
Comprehensive Health and Developmental History
A comprehensive health and developmental history must include the child's physical, developmental, mental, nutrition and tuberculosis health histories. An interim history is performed at each checkup.
Developmental Surveillance or Screening - Developmental surveillance or screening must be performed at each checkup for clients birth through 6 years of age. Developmental and autism screening must be performed at ages noted on the periodicity schedule. Providers must use one of the following validated, standardized tools when performing developmental screening: the Ages and Stages Questionnaire (ASQ), Ages and Stages Questionnaire: Social Emotional (ASQ:SE), or the Parents' Evaluation of Developmental Status (PEDS), and the Modified Checklist for Autism in Toddlers (M-CHAT) for autism screening at 18 months of age. Providers may receive separate reimbursement, in addition to reimbursement for the checkup, when using these tools as part of the checkup at the specified ages. Developmental surveillance is required at all other checkups and includes a review of milestones and mental health, including: gross and fine motor skills, communication skills, speech-language development, self-help/care skills and social, emotional, and cognitive development.
Mental Health - Mental health screening is required at each THSteps checkup and includes behavioral, social, and emotional development. An emergency mental health referral for evaluation and/or treatment must always be made when suicidal thoughts, threats, or behaviors and/or homicidal thoughts, threats, or behaviors are identified during a mental health screening. Whenever an urgent mental health crisis is suspected, every effort must be made to secure a prompt mental health evaluation and any medically necessary treatment for the client. A provider conducting the mental health screen may choose to evaluate and provide mental health services if the provider has the appropriate training and credentials, or refer the client to a qualified mental health specialist. Providers who do not have these qualifications must refer clients to a qualified mental health specialist for such care.
Nutritional Screening - Dietary practices should be assessed to identify unusual eating habits such as pica, extended use of baby bottle feedings, or eating disorders in older children and adolescents. For nutritional problems, further assessment is indicated.
Tuberculosis (TB) Screening
- The Tuberculosis (TB) Questionnaire must be administered annually beginning at 12 months of age. A Tuberculin Skin Test (TST) is to be administered when the screening tool indicates a risk for possible exposure. Providers may receive separate reimbursement, in addition to reimbursement for the checkup, when administering a TST as part of the checkup. The TB Questionnaire can be found on the Texas Health Steps website at www.dshs.state.tx.us/thsteps/forms
or on the back side of the Child Health Clinical Record forms found on the same site. TB risk levels by county may be found on the Tuberculosis website at www.dshs.state.tx.us/idcu/disease/tb/
. For information related to children in foster care, link to http://www.dshs.state.tx.us/idcu/disease/tb/policies/
; then scroll down and select “Tuberculin Skin Testing Guidelines for Children in Various Settings”.
Comprehensive Unclothed Physical Examination
A complete physical examination is required at each visit. A comprehensive unclothed physical examination includes all the components listed below:
Measurements - Requires documentation of measurements and percentiles as appropriate:
- Length or height and weight;
- Fronto-occipital circumference - Birth through 24 months of age;
- Body Mass Index (BMI) - Beginning at 2 years of age; and,
- Blood pressure - Beginning at 3 years of age.
CDC recommends that health care providers:
- Use the WHO growth standards to monitor growth for infants and children ages 0 to 2 years of age.
- Use the CDC growth charts for children age 2 years and older.
- Sensory Screening
- Vision Services-Requires subjective and acuity screening at various ages; see THSteps Periodicity Schedule for details.
- Hearing Services-Requires subjective and audiometric screening at various ages; see THSteps Periodicity Schedule for details.
Vision and hearing screenings are not covered when completed to meet day care, Head Start, or school program requirements unless completed during an acute care visit in a clinic setting.
Documentation of test results from a school vision or hearing screening program may replace the required screening if conducted within 12 months of the checkup. A vision and hearing screening must be completed according to the requirements of the THSteps Periodicity Schedule.
- Oral Health Services
Limited oral screening for caries and general health of the teeth and oral mucosa is part of the physical examination. In addition to the federal requirements, Texas Health Steps policy requires referral to a dentist at six months of age and every six months thereafter until the dental home has been established.
Reimbursement for Oral Evaluation and Fluoride Varnish in the Medical Home is available to medical checkup providers who have been certified by the Department of State Health Services Oral Health Program to perform these services for Texas Health Steps recipients. The oral evaluation must be performed by a physician, advanced practice registered nurse or physician assistant. For more information, see http://www.dshs.state.tx.us/dental/OEFV.shtm.
Providers must assess the immunization status of clients at every medical checkup and vaccines must be administered according to the current Advisory Committee on Immunization Practices (ACIP). “Recommended Childhood and Adolescent Immunization Schedule. The ACIP schedule can be found at http://www.cdc.gov/vaccines/schedules/index.html. Immunizations must be administered at the time of the checkup unless medically contraindicated or because of parental reasons of conscience, including religious beliefs. Immunizations which may be appropriate based on age and health history but which are medically contraindicated at the time of the screening may be rescheduled at an appropriate time. Providers may not refer clients to local health departments or other providers for immunization administration.
Providers may obtain vaccines free of charge from the Texas Vaccines for Children (TVFC) Program, for clients birth through 18 years old, and must not charge the client for the vaccines. Medicaid does not reimburse for vaccines that are available through TVFC.
A THSteps medical checkup may include various laboratory tests appropriate to age and risk, including blood lead level, anemia screening, or other risk-based screenings such as hyperlipidemia. All laboratory tests (with the exception of screening for hyperlipidemia, type 2 diabetes, syphilis, HIV and point-of-care testing for blood lead level in the provider’s office) must be performed by the DSHS laboratory. Laboratory services are provided by DSHS at no cost to the provider.
- Anemia Screening - Required screening by hemoglobin or hematocrit levels at ages noted on the THSteps Periodicity Schedule. Screening may be completed in the provider's office if there is an urgent need for results, but will not be reimbursed separately.
- Lead Screening - Required screening at ages noted on the THSteps Periodicity Schedule. Initial testing may be performed using a venous or capillary specimen and must either be sent to the DSHS lab or performed in the provider's office by point-of-care testing. Point-of-care lead testing, when preformed in the provider's office may be reimbursed separately. All point-of-care blood lead level results must be reported to DSHS. Confirmatory tests must be performed using a venous specimen. Confirmatory specimens may be sent to the DSHS lab or the client or specimen may be sent to the lab of the provider's choice. All blood lead levels for clients who are 14 years of age or younger must be reported to DSHS.
- Newborn Screening - Second screening required at the two-week checkup, but no earlier than seven days after delivery.
- Risk Based Screenings - Screenings performed based on risk assessments include screenings for type 2 diabetes, hyperlipidemia, gonorrhea and chlamydia, HIV, and syphilis. The specimen or client may be sent to the lab of the provider's choice, with the exception of gonorrhea and Chlamydia testing. These specimens must be sent to the DSHS laboratory.
Health education and counseling including anticipatory guidance must be provided at each checkup and documentation must include the time period recommended for the next appointment.
Health education is designed to help parents and caregivers understand what to expect in terms of the child's development and to provide information for all ages about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. Age-appropriate topics include, but are not limited to nutrition and crib safety (infants), reading and toilet training (toddlers), puberty and physical changes (older children) and mental health and communications with family and trusted adults (adolescents). Lead risk assessment should be done through anticipatory guidance. Suggested topics are found on the back side of the Texas Health Steps Child Health Record forms at www.dshs.state.tx.us/thsteps/forms.