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:
- Well-Child Visits in the First 15 Months: Six well-child visits are required to meet this HEDIS measure
- 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.pdfChild 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-resourcesIf 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