Provider Alert! Well Child and Texas Health Steps Visit reminder

Provider Alert! Well Child and Texas Health Steps Visit reminder

Date: November 22, 2021

Attention: PCP, OB/GYN and Endocrinologist Providers

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) would like to remind you of the National Committee for Quality Assurance (NCQA) HEDIS Technical Specifications.

How this impacts providers:

Please submit all claims timely, as soon as services are rendered, and use appropriate codes to reflect the services provided particularly for Well-Care Visits and THSteps.

Well-Child Visits in the First 30 Months of Life (W30)

  • Two rates will be measured:
    1. Well-Child Visits in the First 15 Months: Six well-child visits are required to meet this HEDIS measure
    2. Well-Child Visits for Age 15 Months – 30 Months: Two well-child visits are required to meet this HEDIS measure
  • The following table lists the number of visits billable at each age range:
Age Range  Number of visits
Birth through 11 months (does not include 12 month checkups) 6
1 through 4 years 7
5 through 11 years 7
12 through 7 years 6
18 through 20 years 3
  • Compliance will be calculated directly from claims or encounters submission
  • Telehealth included as an acceptable code1 (see THSteps guidance on appropriate billing below)

Please make sure to submit THSteps claims timely using the appropriate codes to get credit for the visits.

Age Range CPT Codes (new patients) CPT Codes (established patients) ICD-10 Diagnosis Codes
0-7 days  99381  99391  Z00.110
 8-28 days  99381  99391  Z00.111
 29-364 days  99381  99391  Z00.121*, Z00.129**…
 12-30 months  99382  99392  Z00.121*, Z00.129**…

* With abnormal findings
** Without abnormal findings

NOTE: Both CPT and appropriate ICD-10 codes must be present for claim to be paid.
Claims should be billed using only the child’s Medicaid number.

Additional CPT codes for well child checks Outpatient visit:


The following codes will count as a well-child visit for HEDIS: 99381,99382,99383,99384,99385,99391,99392,99393,99394,99395.

For Texas Health Steps Follow-up visit use procedure code 99211 when billed with a THSteps diagnosis.


Source: https://www.tmhp.com/sites/default/files/file-library/texas-health-steps/THSteps_QRG.pdf

Child and Adolescent Well-Care Visits (WCV)

  • Combination measure
  • Measure encompasses 3-20 years old
  • Compliance will be calculated directly from claims or encounters submission
  • Included telehealth as acceptable code (see THSteps guidance on appropriate billing below)
  • Some of the requirements (like immunizations and physical exams) with a well-child visit require an in-person visit. The follow-up code for this visit is 99211 along with the appropriate diagnosis code. Providers must follow-up with their patients within six months of the telemedicine visit to ensure completion of any components.

Please make sure to submit claims timely using the appropriate codes to get credit for the visits.

Age Range CPT Codes (new patients) CPT Codes (established patients) ICD-10 Diagnosis Codes
3-4 years 99382 99392 Z00.121*, Z00.129**
5-11 years 99383 99393 Z00.121*, Z00.129**
12-17 years 99384 99394 Z00.121*, Z00.129**……
18-20 years 99385 99395  Z00.00*, Z00.01**…

* With abnormal findings
** Without abnormal findings

Note: Both CPT and appropriate ICD-10 codes must be present for claim to be paid. Claims should be billed using only the child’s Medicaid number.

Guidance for Texas Health Steps (THSteps):

Due to the ongoing pandemic, HHSC is allowing Telehealth visits for THSteps for children over 24 months of age.

Providers must use the appropriate Place of Service (POS) Code with Telehealth Modifier 95 to ensure timely and accurate claims processing.

Place of Service Code  Modifier 
 02, 11, 50, 72  95

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

  • Allowed member-reported biometric values (body mass index, height and weight)
  • Telephone visit, e-visit or virtual check-in meet criteria
  • Measures encompasses members ages 3-17

Nutrition counseling coding information

Code System Definition Code
 CPT  Medical Nutrition Therapy- Initial assessment and intervention  97802
 CPT  Medical Nutrition Therapy- Reassessment and intervention  97803
 CPT  Medical Nutrition Therapy- Group (two or more)  97804
 ICD-10  Dietary counseling and surveillance  Z71.3

BMI Percentile

Code system Definition Code
 ICD-10  <5th percentile  Z68.51
 ICD-10 5th to <85th percentile  Z68.52
 ICD-10  85th to <95th percentile  Z68.53
 ICD-10  >/=95th percentile  Z68.54

Physical activity counseling

Code System  System Definition  Code
 ICD-10 Encounter for examination for participation in sport Z02.5
 ICD-10 Exercise counselin Z71.82

Next steps for providers:

Providers should implement protocols to improve their compliance rate if needed.

We have developed HEDIS Toolkits that contain helpful information regarding the measure requirements, standards and codes to use that are acceptable for HEDIS reporting. The toolkit is available here: https://www.texaschildrenshealthplan.org/for-providers/provider-resources/hedis-toolkit

TCHP uses Inovalon, a HEDIS certified software, to calculate HEDIS rates. Included are historic claims from TMHP files, as well as information from ImmTrac, the State’s immunization registry. Providers should report their completed patient’s immunization with correct vaccine codes regularly so records are up to date and accurate. IMMTrac: The Texas Immunization Registry; https://www.dshs.texas.gov/immunize/ImmTrac/provider-resources

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers

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