February 2017

Texas Health Steps – Medical Documentation for Checkups

As a Texas Health Steps (THSteps) provider, you affect the lives of many young Texans, and the Health and Human Services Commission (HHSC) understands that documenting the THSteps components of checkups can be challenging.

One federal and two state-contracted reviews of medical records have shown that missing documentation is the largest factor and the primary cause of records being reviewed and money being recouped. HHSC would like to assist you in documenting all of the required components and elements of the THSteps checkups in order to reflect the work you perform to complete each checkup.

THSteps checkups are made up of six primary components. Many of the primary components include individual elements, and each are outlined in the Texas Health Steps Medical Checkup Periodicity Schedule found on the THSteps Provider Information web page. For providers to be reimbursed, each of the following six checkup components and their individual elements must be completed and clearly documented in the medical record:

1. Comprehensive Health and Developmental History – This includes nutrition screenings, developmental and mental health screenings, and TB screenings. The medical record must contain documentation on all screening tools used for TB, growth and development, autism and mental health screenings. The results of these screenings and any necessary referrals must be documented in medical records.
2. Comprehensive Unclothed Physical Esxamination – This includes measurements of height or length, weight, fronto-occipital circumference, BMI, blood pressure, and vision and hearing screenings.
3. Appropriate Immunizations – This is established by the Advisory Committee on Immunization Practices, according to age and health history, including influenza, pneumococcal and HPV.
4. Appropriate Laboratory/Screening Tests – This includes newborn screenings, blood-lead level assessment, appropriate for age and risk factors, and anemia.
5. Health Education (including anticipatory guidance)
6. Oral Health Referral – This establishes a main dentist beginning at six months of age, then every six months until the parent or caregiver reports a dental home has been established.

Any component or element not completed must be noted in the medical record, along with the reason it was not completed and the plan to complete the component or element. THSteps checkups are subject to retrospective review and possible recoupment if the medical record does not include all required documentation.

Information on checkup documentation is available within THSteps Online Provider Education modules. These modules are free and offer continuing education for health care professionals.

The following documents can be used as resources to assist you in completing THSteps checkup documentation:

1. THSteps Clinical Record Review Tool with Instructions (Excel) – This clinical record review tool is available to assist you with self-auditing when preparing for health plan quality reviews. This electronic format will self-populate totals with numerical values.
2. THSteps Clinical Record Review Tool (PDF) – This PDF is the clinical record review tool to use as a paper copy. For paper format use see the “QA Instructions” tab in the Excel file.
3. THSteps Regional Provider Relations Representatives Contact List (PDF) – THSteps Provider Relations regional staff are available to show you and your staff process efficiencies that have been implemented by other providers, and their expertise on checkup documentation requirements.

The care you provide to children can be complicated and difficult. It is important in all aspects of the process to acknowledge your work through adequate and complete documentation.

Thank you for all you do for the health and well-being of children and adolescents across Texas.

For BCBSTX Medicaid (STAR) and CHIP quality inquiries, please contact Kathleen Thompson, Manager Medicaid Quality, kathleen_m_thompson@bcbstx.com, 512-349-4836.