Provider Alert! Coding Guidance for Identifying Members for Case Management

Date: August 22, 2022

Attention: All 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) has an extensive case management program available to our Members. To find out more information on this program, please see our provider manuals.

While active Members can choose to enroll in the program themselves, we also like to outreach to our chronically ill Members not currently registered. We feel that these Members will greatly benefit from the program and we encourage their participation. This is where we are looking for provider support – TCHP would like to remind providers of the importance of properly coding for chronic illnesses during both well-child and sick visits. Helping Members with managing their condition and achieving their optimal health is our ultimate goal.

How this impacts providers: The HEDIS toolkits offer information regarding current procedural terminology (CPT) codes for new and established patients for well-child visits.

To ensure your patient’s complete medical history is captured, including chronic conditions, it is important to include all appropriate diagnosis codes on submitted claims. Complete and current patient history allows for continuity and coordination of care between your patient’s entire care team.

For well visits, the correct CPT code should be applied based on patient status, and the chronic illness code should be added as a secondary code. This can occur for both well-child visits and sick visits. Both CPT and appropriate ICD-10 codes must be present for claim to be paid. Claims should be billed using the child’s Medicaid number

Providers are encouraged to use diagnosis codes and refer to the guide for more information. We also advise providers to actively outreach to their assigned members that are due for a checkup and schedule appointments in order to renew prescriptions timely.

View the quick reference guide here: https://www.texaschildrenshealthplan.org/for-providers/provider-resources/hedis-toolkit

Next steps for providers: Providers should share this communication with their staff.

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.