Provider Alert! Texas Health Steps (THSteps) and CHIP medical checkups via remote delivery

Date: May 25, 2022

Attention: Primary Care Physicians

Effective Date: Dates of Service May 7, 2020 – End of Public Health Emergency

The content in this message will remain in effect through the end of the public health emergency, as announced by the Health and Human Services Commission.

TCHP COVID-19 Utilization Management Procedure and TCHP provider alerts can be found here: http://www.thecheckup.org/provider-alerts/

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) supports the Health and Human Services Commission’s (HHSC) guidance on remote delivery of THSteps visits. TCHP extends this direction to include CHIP well-child visits during implementation of COVID-19 restrictions. This guidance is effective from May 7, 2020 through the end of the public health emergency. HHSC will be evaluating extension periods for this and other COVID-19 policies. To allow for continued delivery of THSteps checkups during the period of social distancing due to COVID-19, HHSC is permitting the following:

• HHSC is allowing remote delivery of certain components of medical checkups for children over 24 months of age beginning with the 30-month checkup.
  • Telemedicine or telephone-only delivery of THSteps checkups or CHIP well-child visits for children birth through 24 months of age (i.e. from the first newborn checkup through the “24 month” checkup) is not permitted.
• Some of these requirements (like immunizations and physical exams) require an in-person visit; providers must follow-up with their patients within six months of the telemedicine visit to ensure completion of any components.

Texas Health Steps Telemedicine Guidance for Providers
Visit https://www.hhs.texas.gov/sites/default/files/documents/services/health/coronavirus-covid-19/thsteps-telemedicine-guidance-providers.pdf  for guidance permitting remote delivery of certain components of Texas Health Steps medical checkups.

THSteps medical checkups and CHIP well-child visits require the following federally mandated components:

• Comprehensive health and developmental history, including physical and mental health and development
• Comprehensive unclothed physical examination
• Immunizations appropriate for age and health history
• Laboratory tests appropriate to age and risk, including lead toxicity screening
• Health education, including anticipatory guidance

How this impacts providers: Providers should use their clinical judgement as to what components of the checkup may be appropriate for telemedicine (audio + visual) or telephone only delivery. The following are recommendations from HHSC.

• Audio + visual delivery is preferred over telephone-only.
• Physicians (MD and DO), nurse practitioners, physician assistants, and registered nurses may perform remote delivery of these services.
• Non-physician provider supervision and delegation rules/regulations still apply. Providers should refer to State Practice rules and National guidelines regarding supervision requirements and practice accordingly.

Billing information: Providers should bill using the appropriate coding for THSteps checkups and CHIP well-child visits for the initial visit as is currently required and adhere to the following guidance.

• Providers may also bill for “add-on” codes (e.g. developmental screening, mental health screening, etc.) as they normally would.
• Modifier 95 must be included on the claim form to indicate remote delivery.
• Provider documentation should include the components that were not completed during the initial checkup using COVID-19 as the reason for an incomplete checkup.
• When the patient is brought into the office within the six-month timeframe to complete the outstanding components of the visit, providers should bill the follow-up visit code (99211).
• There are three exceptions to periodicity modifiers for THStep visits. One of them must be included when billing the six- month in-office visit to indicate that the visit was off- cycle.
  • 23 Unusual Anesthesia, 32 Mandated Services, SC Medically Necessary
• Providers may also bill an acute care E/M code at the time of the initial telemedicine checkup or at the “6-month” follow-up visit. Modifier 25 must be submitted with the acute care E/M procedure code to signify the distinct service rendered. Providers must bill the acute care visit on a separate claim without benefit code EP1.
• Acceptable reasons for which the 6-month timeframe might not be met include, but are not limited to, the following:
  • Child moves (from one service delivery area into another)
  • Child switches primary care providers
  • Child changes product service lines (e.g. from STAR to STAR Kids)
  • Child switches MCOs
  • Child moves out of state
  • Child dies
  • Child loses eligibility
  • It is still not safe in 6 months to conduct an in-person visit
• Reimbursement will be identical to current rates for THSteps checkup codes.
• This guidance applies to both new and established patients and is applicable for members in both managed care and fee-for-service Medicaid and CHIP.

Three-day medical exam: The 3-Day medical exam required by statute for children entering the Department of Family and Protective Services (DFPS) conservatorship, telemedicine or telephone-only delivery will not be permitted, regardless of age, with one notable exception:

• If a youth requires quarantine or isolation at the time of removal due to COVID-19 exposure or because the youth is known to be infected, remote delivery is allowed.
• Telemedicine, telehealth, or telephone-only will be allowed in this circumstance to avoid the risk of transmission in a health care setting, and audio + visual delivery is preferred, although telephone-only delivery will be permitted when audio + visual is not possible.
• Documentation should detail the circumstances, which necessitated remote delivery.  Providers should include modifier 95 when submitting a claim, as well as the appropriate Place of Service (POS) code.

Next steps for providers: Providers should follow the detailed guidance presented previously and explore different ways to ensure delivery of age-appropriate vaccines for children over two years old in a timely manner.

Resources:

Texas Health Steps quick reference guide; http://www.tmhp.com/TMHP_File_Library/Provider_Manuals/THStepsQRG/THSteps_QRG.pdf

Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents;
https://www.dshs.texas.gov/uploadedFiles/Content/Family_and_Community_Health/thsteps/pdfdocs/PS_large_2018.pdf

American Academy of Pediatrics (AAP) website to include curb-side/drive-through immunization clinics; https://www.aap.org/en-us/Pages/Default.aspx.

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.