Below is a summary of the federal and state mandated components of a Texas Health Steps medical checkup that 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, Children's Services Handbook.
The Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents (birth through 20 years of age) [PDF] is a guide for Texas Health Steps providers to understanding the age-appropriate requirements for each checkup.
Forms and screening tools mentioned below are available on the Texas Health Steps Forms page.
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 client's birth through 6 years of age.
Developmental screening must be performed at ages noted on the Texas Health Steps Periodicity Schedule (PDF). Providers must use one of the following validated, standardized tools:
- Ages and Stages Questionnaire (ASQ)
- Ages and Stages Questionnaire: Social Emotional (ASQ:SE)
- Parents' Evaluation of Developmental Status (PEDS)
Autism screening must be performed at ages noted on the Texas Health Steps Periodicity Schedule (PDF). Providers must use one of the following tools:
- Modified Checklist for Autism in Toddlers (M-CHAT™)
- Modified Checklist for Autism in Toddlers, Revised with Follow-up Questions (M-CHAT-R/F™)
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 screening is required at each Texas Health Steps checkup and includes behavioral, social, and emotional development.
Maternal postpartum depression screening is recommended for all infants. Effective July 1, 2018, maternal postpartum depression screening may be completed during an infant's Texas Health Steps checkup prior to the infant's first birthday. Providers may receive separate reimbursement, in addition to reimbursement for the checkup, when screening using a validated screening tool. A provider may receive separate reimbursement only once per infant.
Validated maternal postpartum depression screening tools include:
- Edinburgh Postnatal Depression Scale
- Patient Health Questionnaire (PHQ-9)
- Postpartum Depression Screening Scale
Mental health screening is recommended annually for all clients who are 12 through 18 years of age. Providers may receive separate reimbursement, in addition to reimbursement for the checkup, when screening using a validated screening tool.
Validated, standardized mental health screening tools include:
- Pediatric Symptom Checklist (PSC-17)
- Pediatric Symptom Checklist (PSC-35)
- Pediatric Symptom Checklist for Youth (Y-PSC)
- Patient Health Questionnaire (PHQ-9)
- Patient Health Questionnaire Modified for Adolescents (PHQ-A [depression screen])
- Car, Relax, Alone, Forget, Family, and Trouble Checklist (CRAFFT)
- Patient Health Questionnaire for Adolescents (PHQ-A [anxiety, eating problems, mood problems and substance abuse screen])
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.
The Tuberculosis Questionnaire must be administered annually beginning at 12 months of age. A Tuberculin Skin Test 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.
Comprehensive Unclothed Physical Examination
A complete physical examination is required at each visit. A comprehensive unclothed physical examination includes all the components listed below.
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)
- Blood pressure (beginning at 3 years of age)
Texas Health Steps recommends that health care providers:
- Use the World Health Organization (WHO) growth charts for infants and children birth to 2 years of age.
- Use the Centers for Disease Control and Prevention (CDC) growth charts for children who are 2 years of age or older.
- Vision Services: Requires subjective and acuity screening at various ages. See the Texas Health Steps Periodicity Schedule (PDF) for details.
- Hearing Services: Requires subjective and audiometric screening at various ages. See the Texas Health Steps Periodicity Schedule (PDF) 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 Texas Health Steps Periodicity Schedule.
Oral Evaluation and Varnish in the Medical Home
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 Texas Health Steps 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, visit the Texas Health Steps OEFV website.
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 CDC Immunization Schedules website.
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. Providers must not charge the client for the vaccines. Medicaid does not reimburse for vaccines that are available through TVFC.
A Texas Health Steps 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 dyslipidemia. All laboratory tests (with the exception of screening for dyslipidemia, 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 Texas Health Steps Periodicity Schedule (PDF). Screening may be completed in the provider's office if there is an urgent need for results, but will not be reimbursed separately.
- Dyslipidemia Screening: Required screening at ages noted on the Texas Health Steps Periodicity Schedule (PDF). Risk-based screening may also be completed at other ages.
- HIV Screening: Required screening at ages noted on the Texas Health Steps Periodicity Schedule (PDF). Risk-based screening may also be completed at other ages.
- Lead Screening: Required screening at ages noted on the Texas Health Steps Periodicity Schedule (PDF). Initial testing may be performed using a venous or capillary specimen and must either be sent to the DSHS Laboratory 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 Laboratory 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: The second screening is required at the two-week checkup, but no earlier than seven days after delivery.
- Critical Congenital Heart Disease Screening: The screening is mandatory in Texas, and must be performed at the birth facility prior to discharge.
- Risk-based Screenings: Screenings performed based on risk assessments include screenings for type 2 diabetes, dyslipidemia, 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 Anticipatory Guidance
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. Suggested topics are found on the Anticipatory Guidance (PDF) and on the back side of the Texas Health Steps Child Health Record forms.
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.