Preventative Care &

SCREENING GUIDELINES

Thank you for joining the CHRISTUS Health Plan Network. We appreciate your partnership and shared desire to make excellent health care more accessible to those in our community. You are at the core of who we are, and everything we can accomplish begins with you. This handy manual is a small token of appreciation that we hope will help you provide the best care possible to your patients. Together, we will help our community be as strong and healthy as it can be! Note: CHRISTUS Health Plan star members must have a Texas Health checkup within the first 90 days of enrollment.

1-844-282-3100 • www.christushealthplan.org

BIRTH THROUGH 30 MONTHS OF AGE

Checkup Periodicity Table Comprehensive Health Screening*

LABORATORY TESTS

Anemia Hyperlipidemia Health Education/ Anticipatory Guidance

VISION HEARING

Blood Lead Screening

MEASUREMENTS

Subjective Vision

AGE

History Nutritional Screening Review of Milestones ASQ, ASQ:SE, or PEDS M-Chat Mental Health: Psychosocial/Behavioral Health Screening TB Questionnaire with Skin Test if Risk Identified Unclothed Physical Examination Length Weight BMI Fronto-Occipital Circumference

DEVELOPMENTAL SURVEILLANCE

Newborn Hearing Test (OAE or ABR) Subjective Hearing Dental Referral Screen/Administer Immunizations According to ACIP Guidelines Newborn Screening Panel

* Comprehensive Health Screening, as indicated below, consists of federal and state components that are required for the checkup to be considered complete. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for further details at: www.dshs.state.tx.us/thsteps/providers.shtm

Months

Newborn D/C to 5 days 2 weeks 2 4 6 9 12 15 18 24 30 Legend of Symbols Mandatory at this age. If a component is not completed at the required age, it is mandatory for the provider to complete at the first opportunity if age-appropriate. When symbols appear at the same age for developmental, vision, or hearing screening, perform the most appropriate level screen. Risk-based. Note: THSteps components may be performed at other ages if medically necessary. Check regularly for updates to this schedule: www.dshs.state.tx.us/thsteps/providers_ components.shtm. For free online provider education: www.txhealthsteps.com

Checkup Periodicity Table Comprehensive Health Screening*

3 THROUGH 10 YEARS OF AGE

Years

Health Education/Anticipatory Guidance

Type 2 Diabetes

Hyperlipidemia

LABORATORY TESTS

Blood Lead Screening

Screen/Administer Immunizations According to ACIP Guidelines

Dental Referral

Subjective Hearing

HEARING

Audiometric Screening

Visual Acuity

VISION

Blood Pressure

BMI

Weight

MEASUREMENTS

Height

Unclothed Physical Examination

TB Questionnaire with Skin Test if Risk Identified

ASQ, ASQ:SE, or PEDS

Review of Milestones

AGE

Nutritional Screening

History

DEVELOPMENTAL SURVEILLANCE

Mental Health: Psychosocial/ Behavioral Health Screening

* Comprehensive Health Screening, as indicated below, consists of federal and state components that are required for the checkup to be considered complete. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for further details at: www.dshs.state.tx.us/thsteps/providers.shtm

3 4 5 6 7 8 9 10

Legend of Symbols Mandatory at this age. If a component is not completed at the required age, it is mandatory for the provider to complete at the first opportunity if age-appropriate. When symbols appear at the same age for developmental, vision, or hearing screening, perform the most appropriate level screen. Risk-based. Note: THSteps components may be performed at other ages if medically necessary. Check regularly for updates to this schedule: www.dshs.state.tx.us/thsteps/providers_ components.shtm. For free online provider education: www.txhealthsteps.com

11 THROUGH 20 YEARS OF AGE

Checkup Periodicity Table Comprehensive Health Screening*

Years

Health Education/ Anticipatory Guidance

HIV Test

STD/STI Screening

Type 2 Diabetes

Hyperlipidemia

LABORATORY TESTS

Anemia

Screen/Administer Immunizations According to ACIP Guidelines

Dental Referral

Subjective Hearing

HEARING

Audiometric Screening

Subjective Vision

Visual Acuity

VISION

Blood Pressure

BMI

Weight

Height

MEASUREMENTS

Unclothed Physical Examination

TB Questionnaire with Skin Test if Risk Identified

Mental Health: Psychosocial/Behavioral Health Screening

AGE

Nutritional Screening

History

* Comprehensive Health Screening, as indicated below, consists of federal and state components that are required for the checkup to be considered complete. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for further details at: www.dshs.state.tx.us/thsteps/providers.shtm

11 12 13 14 15 16 17 18 19 20

Legend of Symbols Mandatory at this age. If a component is not completed at the required age, it is mandatory for the provider to complete at the first opportunity if age-appropriate. When symbols appear at the same age for developmental, vision, or hearing screening, perform the most appropriate level screen. Risk-based. Females screened once between 12 and 16 years of age. Note: THSteps components may be performed at other ages if medically necessary. Check regularly for updates to this schedule: www.dshs.state.tx.us/thsteps/providers_ components.shtm. For free online provider education: www.txhealthsteps.com

BILLING PROCEDURE CODES

THSteps Medical Checkup

Remember: Use Provider Identifier • Benefit Code EP1 • Diagnosis Code V202 THSteps Medical Checkups

Developmental and Autism Screening

99381

99382

99383

99384

99385

99391

99392

99393

99394

99395

THSteps Follow-up Visit

Developmental screening with use of the ASQ, ASQ:SE or PEDS is reported using procedure code 96110. Autism screening with use of the M-CHAT is reported using procedure code 96110 with U6 modifier.

Use procedure code 99211 for a THSteps follow-up visit.

Tuberculin Skin Testing (TST)

Oral Evaluation and Fluoride Varnish

Use procedure code 86580 for TST. Procedure code 86580 may be reimbursed on the same day as a checkup.

Use procedure code 99429 with U5 modifier.

Point-of-Care Lead Testing Use procedure code 83655 with QW modifier to report that an initial blood lead level screening test was completed using point-of-care testing.

BILLING PROCEDURE CODES (cont.)

THSteps Medical Checkup Immunizations Administered Procedure Codes 90632 or 90633* with (90460/90461 or 90471/90472) 90636 with (90460/90461 or 90471/90472) 90644 90647* or 90648* with (90460/90461 or 90471/90472) 90649* or 90650* with (90460/90461 or 90471/90472) 90654, 90655*, 90656*, 90657*, 90658*, or 90686*, with (90460/90461 or 90471/90472) or 90660*, with (90460/90461 or 90473/90474) or 90672*, with (90460/90461 or 90473/90474) or 90673 with (90471/90472) 90669 or 90670* with (90460/90461 or 90471/90472) 90680* or 90681* with (90460/90461 or 90473/90474) 90696* with (90460/90461 or 90471/90472) 90698* with (90460/90461 or 90471/90472) * Indicates a vaccine distributed by TVFC

Vaccine Hep A Hep A/Hep B Hib-MenCY Hib HPV Influenza

PCV7, PCV13 Rotavirus DTaP-IPV DTap-IPV-Hib

Immunizations Administered Procedure Codes 90700* with (90460/90461 or 90471/90472) 90702* with (90460/90461 or 90471/90472) 90703 with (90460/90461 or 90471/90472) 90707* with (90460/90461 or 90471/90472) 90710* with (90460/90461 or 90471/90472) 90713* with (90460/90461 or 90471/90472) 90714* with (90460/90461 or 90471/90472) 90715* with (90460/90461 or 90471/90472) 90716* with (90460/90461 or 90471/90472) 90721 with (90460/90461 or 90471/90472) 90723* with (90460/90461 or 90471/90472) 90732* with (90460/90461 or 90471/90472) 90733 or 90734* with (90460/90461 or 90471/90472) 90743, 90744*, or 90746 with (90460/90461 or 90471/90472) 90748* with (90460/90461 or 90471/90472) * Indicates a vaccine distributed by TVFC

Vaccine DTaP DT Tetanus MMR MMRV IPV Td Tdap Varicella DTaP-Hib DTap-Hep B-IPV PPSV23 Meningococcal Hep B Hib-Hep B

BILLING PROCEDURE CODES (cont.)

THSteps Medical Checkup

Modifiers

Condition Indicator Codes

Performing Provider Use to indicate the practitioner who is performing the unclothed physical examination component of the medical checkup.

Use one of the indicators below if a referral was made.

AM

Condition Indicator

Condition Indicator Codes

Description

N

NU

Not used (no referral)

Y

ST

New services requested

Y

S2

Under treatment

SA

TD

U7

Exception to Periodicity Use with THSteps medical checkups procedure codes to indicate the reason for an exception to periodicity. 23

32

SC

FQHC and RHC Federally qualified health center (FQHC) providers must use modifier EP for THSteps medical checkups. Rural health clinic (RHC) providers must bill place of service 72 for THSteps medical checkups. Vaccine/Toxoids Use to indicate a vaccine/toxoid not available through TVFC and the number of state defined components administered per vaccine. U1

Vaccine/toxoid privately purchased by provider when TVFC vaccine/toxoid is not available

CPT codes, descriptions, and other data only are copyright 2013 American Medical Association (or such other date of publication of CPT). All Rights Reserved. CPT is a trademark of the AMA. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.

Recommended Adult Immunization Schedule — United States 2014

CHART 1. BY VACCINE AND AGE GROUP

Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information. VACCINE



AGE GROUP

Influenza2,* Tetanus, diphtheria, pertussis (Td/Tdap)3,* Varicella4,* Human papillomavirus (HPV) Female5,* Human papillomavirus (HPV) Male5,* Zoster6 Measles, mumps, rubella (MMR)7,* Pneunococcal 13-valent conjugate (PCV13)8,* Pneunococcal polysaccharide (PPSV23)9,10 Meningococcal11,* Hepatitis A12,* Hepatitis B13,* Haemophilus influenzae type b (Hib)14,*

19–21 years

22–26 years

27–49 years

50–59 years

1 dose annually

60–64 years

≥ 65 years

Substitute 1-time dose of Tdap for Td booster; them boost with Td every 10 yrs 2 doses 3 doses 3 doses 1 dose 1 or 2 doses 1 dose 1 or 2 doses

1 dose

1 or more doses 2 doses 3 doses 1 or 3 doses

* Covered by the Vaccine Injury Compensation Program Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on For all persons in this category who meet the age requirements filing a VAERS report are available at www.vaers.hhs.gov or by telephone, 800–822–7967. and who lack documentation Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation or by telephone, of vaccination or have evidence 800–338–2382. The file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; of previous infection; zoster telephone, 202–357–6400. vaccine recommended Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at regardless of prior episode of www.cdc.gov/vaccines or from the CDC-INFO Contact Center at 800–CDC–INFO (800–232–4636) in English and Spanish, 8:00 a.m.–8:00 p.m. Eastern zoster Time, Monday–Friday, excluding holidays. Recommended if some other Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human risk factor is present (e.g., on the Services. basis of medical, occupational, The recommendations in this schedule were approved by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization lifestyle, or other indication) Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), American College of Obstetricians and No recommendation Gynecologists (ACOG) and American College of Nurse Midwives (ACNM).

Recommended Immunization Schedule

CHART 2. 0-18 YEARS

United States 2014

These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the gray bards below.

Rotavirus2 (RV) RV1 (2-dose series); RV5 (3-dose series) Diphtheria, tetanus, & acellular pertussis3 (DTaP: