5000, Clinical Guidelines

Revision 22-3; Effective Sept. 30, 2022

This section describes the requirements and recommendations for contractors pertaining to the delivery of direct clinical services to clients. In addition to the requirements and recommendations found within this section, contractors should develop protocols consistent with national evidence-based guidelines appropriate to the target population.

5100 General Consent

Revision 22-3; Effective Sept. 30, 2022

Contractors must obtain the client’s written, informed, voluntary general consent to receive services before receiving any clinical services. A general consent explains the types of services provided and how client information may be shared with other entities for reimbursement or reporting purposes. If there is a period of three years or more during which a client does not receive services, a new general consent must be signed before reinitiating delivery of services.

A client’s verbal consent for general treatment may be obtained by phone. This type of consent is adequate for routine treatment provided through telemedicine. In order to record a client’s verbal consent, the staff person obtaining the consent must read the consent form to the applicant and document that the applicant affirms by giving their verbal consent for treatment. The documentation must include the date and time of the applicant’s consent and the signature of the staff person obtaining consent. The client must sign the consent at the time of their next visit to the clinic. 

Consent information must be effectively communicated to every client in a manner that is understandable. This communication must allow the client to participate, make sound decisions about their own medical care and address any disabilities that impair communication, in compliance with Limited English Proficiency regulations. Only the client may consent, except when the client is legally unable to consent (i.e., a minor or a person with a development disability), to which a parent, legal guardian or caregiver must consent on his or her behalf. Consent must never be obtained in a manner that could be perceived as coercive. 

HHSC contractors should consult a qualified attorney to determine the appropriateness of the consent forms used by their health care agency.

Consent for Dental Procedures

Written informed consent for dental procedures must be obtained in compliance with 22 Texas Administrative Code Section 108.7 regarding minimum standards of care for dentists.

Texas Medical Disclosure Panel Consent

The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to:

  • determine which risks and hazards about medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients; and
  • establish the general form and substance of such disclosure.

The contractor is responsible for assuring that informed consent is obtained from the patient for procedures per TMDP. TMDP has developed List A (informed consent requiring full and specific disclosure) for certain procedures, and is found in 25 TAC Section 601.2.

For all other procedures not listed on List A, the physician must disclose, through a procedure specific consent, all risks that a reasonable client would want to know. This includes:

  • all risks that are inherent to the procedure meaning one that exists in and is inseparable from the procedure itself; and 
  • that are material and could influence a reasonable person in deciding whether to consent to the procedure. 

Consent for Services Provided to Minors

Generally, a parent must consent to treatment for minors. A minor is defined as a person under 18 years old who has never been married and never been declared an adult by a court (emancipated). However, there are certain circumstances when a minor may consent for their own treatment. Requirements for parental consent for provision of family planning services to minors vary according to the funding source subsidizing the services. The department and providers may provide family planning services, including prescription drugs, without the consent of the minor’s parent, managing conservator, or guardian only as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations.

Resources and References

Consent for Human Immunodeficiency Virus (HIV) Tests

For HIV testing, contractors must comply with Texas Health and Safety Code:

  • Section 81.105, regarding Informed Consent; and
  • Section 81.106, regarding General Consent.

5200 Clinical Policy

Revision 22-3; Effective Sept. 30, 2022

Telehealth

Providers may provide services by Telehealth, if appropriate. Telehealth services are defined as health care services delivered by a health professional to a patient at a different physical location than the health professional, using telecommunications or information technology.

Providers who provide Telehealth services must have written policies and procedures for doing so that include the following:

  • clinical oversight by the medical director or designated physician responsible for medical leadership;
  • contraindication considerations for telemedicine use;
  • qualified staff members to ensure the safety of the person being served by telemedicine at the remote site;
  • safeguards to ensure confidentiality and privacy per state and federal laws;
  • services are provided by credentialed licensed providers providing clinical care within the scope of their licenses;
  • demonstrated competency in the operations of the system by all staff members who are involved in the operation of the system and provision of the services before initiating the protocol;
  • priority in scheduling the system for clinical care of individuals;
  • quality oversight and monitoring of satisfaction of the people served; and
  • management of information and documentation for telemedicine services that ensures timely access to accurate information between the two sites.

Client Health Records and Documentation of Encounters

Providers must ensure that a patient health record is established for every person who receives clinical services.

All patient health records must be:

  • Complete, legible and accurate documentation of all client encounters, including those by phone, email or text message.
  • Written in ink without erasures or deletions, or documented in the electronic medical record (EMR) or electronic health record (EHR).
  • Signed by the provider making the entry, including the name of the provider, the provider’s title and the date for each entry.
    • Electronic signatures are allowable to document the encounter or provider review of care.  
    • Stamped signatures are not allowable.
  • Readily accessible to assure continuity of care and availability to clients.
  • Systematically organized to allow easy documentation and prompt retrieval of information.

All client health records must include:

  • client identification and personal data, including financial eligibility;
  • the client’s preferred language and method of communication;
  • client contact information, including the best way and alternate ways to reach the client to ensure continuity of care, confidentiality and compliance with HIPAA regulations;
  • a complete medication list, including prescription and nonprescription medications, as well as dietary supplements, updated at each encounter;
  • a complete listing of all allergies and adverse reactions to medications, food and environmental substances (e.g., latex);
    • if the patient has no known allergies, this should be listed.
    • this information should be prominently displayed in the patient’s record and updated at each encounter;
  • a plan of care, updated as appropriate, consistent with diagnoses and assessments, which are consistent with clinical findings;
  • documentation of recommended follow-up care, scheduled return visit dates and follow-up for missed appointments;
  • documentation of informed consent or refusal of services;
  • documentation of client education and counseling with attention to risks identified through the health risk assessment; and
  • at every visit, the record must be updated as appropriate, documenting the reason for the visit, relevant history, physical exam findings, and pertinent screening and diagnostic tests with results and a treatment plan.

Case Management

Title V case management is for all pregnant women and infants under 1 who need for health-related services.

Referral and Follow-Up

Contractors must have written policies and procedures for follow-up on referrals that are made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to clients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information.

Whenever possible, clients should be given a choice of referral resources to choose from. When a client is referred to another resource because of an abnormal finding or for emergency clinical care, the contractor must::

  • plan for the provision of pertinent client information to the referral resource (obtaining required client consent with appropriate safeguards to ensure confidentiality, i.e., adhering to HIPAA regulations);
  • advise the client about her or his responsibility in complying with the referral;
  • follow up to determine if the referral was completed; and
  • document the outcome of the referral.

Before a contractor can consider a client as “lost to follow-up,” the contractor must have at least three documented separate attempts to contact the client.

The provider must comply with state and local sexually transmitted infection (STI) reporting requirements.

For services determined to be necessary, but not provided by the contractor, refer clients to other resources for care.

5300 Perinatal Clinical Guidelines

Revision 22-3; Effective Sept. 30, 2022

Perinatal Services

Provide prenatal and postpartum services based on American College of Obstetricians and Gynecologists (ACOG) guidelines.

Contractors may bill Title V MCH FFS for allowable services provided in clinical prenatal care visits for women during the CHIP Perinatal Program enrollment process. See workbook for reimbursable procedure codes.

Postpartum visits that are medically necessary are reimbursable and include interval history, physical examination, assessment, family planning, counseling, education and referral, as indicated.

Initial Prenatal Visit Assessment

A comprehensive medical history documented at the initial prenatal visit must at least address the following:

  • current health status, including:
    • symptoms of pregnancy; and
    • acute and chronic medical conditions;
  • significant history, including:
    • hospitalizations;
    • surgeries;
    • biopsies; and
    • blood transfusions and other exposure to blood products;
  • current medications, including prescription, over the counter, and complementary and alternative medications;
  • allergies, sensitivities or reactions to medicines or other substance(s);
  • immunization status or assessment, including Rubella status;
  • mental health assessment including current and past mental health conditions;
  • pertinent history of immediate family, including genetic conditions;
  • pertinent partner history, including:
    • injectable drug use;
    • number of partners STI and HIV history; and
    • other risk factors;
  • reproductive health history must include:
    • menstrual history, including last normal menstrual period;
    • sexual behavior history, including:
      • family planning practices;
      • number of partners;
      • gender of sexual partners; and
      • sexual abuse, as indicated;
    • detailed obstetrical history;
    • gynecological and urologic conditions;
    • STIs, including hepatitis B and C, and HIV risks and exposure;
    • cervical cancer screening history:
      • date and results of last Pap test or other cervical cancer screening test; and
      • note of any abnormal results and treatment;
  • social history and health risk assessment:
    • home environment, to include living arrangements;
    • family dynamics with assessment for family violence including safety assessment, when indicated (mandated by Texas Family Code, Chapter 261);
    • human trafficking;
    • tobacco, alcohol, medications, recreational drug use or abuse and exposure, drug dependency including type, duration, frequency and route;
    • nutritional history;
    • occupational hazards or environmental toxin exposure;
    • ability to perform activities of daily living (ADL);
    • risk assessment, including but not limited to:
      • diabetes;
      • heart disease;
      • intimate partner violence; and
      • injury or malignancy; and
  • review of systems with pertinent positives and negatives documented in the health record.

All initial and routine prenatal visits must include an appropriate physical exam according to the purpose of visit and week of gestation. For any portion of the examination that is deferred, the reason(s) for deferral must be documented in the patient health record.

Initial Prenatal Visit Physical Examination

  • height measurement;
  • weight measurement, with documentation of pre-pregnancy weight and assessment for underweight, overweight and/obesity;
  • blood pressure evaluation;
  • cardiovascular assessment;
  • visual inspection of external genitalia and anus;
  • pelvic exam, including estimate of uterine size (Note: Pelvic exams must be administered per the Chapter 167A of the Health and Safety Code);
  • fetal heart rate for gestational age greater than 12 weeks; and
  • other systems, as indicated by history and the health risk assessment.

Return Prenatal Visits

Interval history, including:

  • symptoms of infections;
  • symptoms of preterm labor;
  • headaches or visual changes;
  • fetal movement that is more than18 weeks;
  • family violence screening when patient is more than 28 weeks;
  • intimate partner violence assessment at least once each trimester;
  • weight measurement;
  • blood pressure evaluation;
  • uterine size and fundal height;
  • fetal heart rate at more than 12 weeks;
  • fetal lie or position at more than 30 weeks; and
  • other systems, as indicated by history or other findings.

Postpartum Visits

Interval history, including:

  • labor and delivery history, noting maternal and neonatal complications;
  • Infant bonding;
  • breastfeeding and infant feeding issues;
  • symptoms of infections;
  • symptoms of excessive or abnormal vaginal bleeding;
  • assessment for postpartum depression  (The Texas Clinician’s Postpartum Depression Toolkit);
  • intimate partner violence assessment;
  • family planning and contraception including current method or future plans;
  • weight;
  • blood pressure evaluation;
  • breast and axilla exam;
  • abdomen exam;
  • pelvic exam, including uterine size (Note: Pelvic exams must be administered per Chapter 167A of the Health and Safety Code); and
  • systems, as indicated by history or risk profile and other findings.

Perinatal Laboratory and Other Diagnostic Tests

Include appropriate laboratory and diagnostic tests, as indicated by weeks of gestation and clinical assessment, in all prenatal visits. Contractors must have written plans to address laboratory and other diagnostic test orders, results and follow-up to include:

  • tracking and documentation of tests ordered and performed for each patient;
  • tracking of test results and documentation in patient records; and
  • a mechanism to address abnormal results, facilitate continuity of care and assure confidentiality, adhering to HIPAA regulations (i.e., making results and interventions accessible to the delivering hospital, facility or provider).

Initial Prenatal Visit Laboratory Tests

Lab tests should be performed as recommended by accepted standards of care for patient’s weeks of gestation or indicated by risk assessment, history or physical exam (see Title V workbook for covered lab tests). The following tests are state-mandated:

Return Prenatal and Postpartum Visits Laboratory and Diagnostic Tests

Lab tests should be performed as recommended by accepted standards of care for patient’s weeks of gestation, mandated by law, and indicated by risk assessment, history or exam (see Title V workbook for covered lab tests).

Diagnostic Tests, Interventions and Special Procedures

Ultrasounds

Obstetrical ultrasounds will be reimbursed as recommended by ACOG guidelines.

Complete ultrasound – A complete evaluation of the pregnant uterus, to include fetal number, viability, presentation, dating measurements, complete anatomical survey; placental localization characterizations and amniotic fluid assessment.

Follow-up or limited ultrasound – A brief, more limited evaluation of the pregnant uterus that may follow a previous complete exam, be it an initial exam before 12 weeks or be it an initial exam after 12 weeks which is limited in scope. Includes fetal number, viability, presentation, dating measurements, limited anatomic assessment, placental localization and characterization, and amniotic fluid assessment.

Non-Stress Test (NST)

Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age is reached. May be billed as often as the provider deems the procedure to be medically necessary.

Biophysical Profile (BPP)/Fetal Biophysical Profile (FBPP)

Prenatal test used to check on a baby's well-being. The test combines fetal heart rate monitoring (nonstress test) and fetal ultrasound to evaluate a baby's heart rate, breathing, movements, muscle tone and amniotic fluid level.

Perinatal Education and Counseling Services

Contractors must have written plans for patient education. These include goals and content outlines to ensure consistency and accuracy of information provided, and that identify mechanisms used to ensure patient understanding of the information. Education must be appropriate to patient’s age, level of knowledge and socio-cultural background and presented in an unbiased manner. Plans for patient education must be reviewed and signed by the medical or dental director at the contracted facility.

Tobacco Assessment and Quit Line Referral

All women receiving prenatal services should be assessed for tobacco use. Women who use tobacco should be referred to tobacco quit lines. The assessment and referral should be performed by agency staff and documented in the clinical record.

Nutrition Counseling

Nutritional counseling by a licensed dietitian is not billable to Title V MCH FFS. Refer to Women, Infants and Children (WIC) for nutritional counseling.

Initial Prenatal Visit Education

Patient education should be based on history, risk assessment and physical exam and must cover the following:

  • nutrition and weight gain;
  • intimate partner violence and abuse;
  • human trafficking;
  • physical activity and exercise;
  • sexual activity;
  • environmental or work hazards;
  • travel;
  • alcohol use and substance abuse;
  • breastfeeding;
  • when and where to obtain emergency care;
  • anticipated course of prenatal care, including prenatal testing;
  • injury prevention, including seat belt use;
  • cocooning infants and children against pertussis (immunization of family members and potential caregivers of the infant);
  • toxoplasmosis precautions;
  • referral to WIC;
  • use of medications; and
  • other education and counseling as indicated by state mandate, risk assessment, history and physical exam.

Return Prenatal Visit Education

Education should be appropriate to weeks/gestation and based on history, risk assessment and physical exam, including but not limited to:

  • signs and symptoms of preterm labor beginning in the second trimester;
  • warning signs and symptoms of pregnancy induced hypertension (PIH);
  • selecting a provider for the infant; and
  • postpartum family planning.

Postpartum Visit Education

Patient education should include:

  • physiologic changes;
  • signs and symptoms of common complications;
  • care of the breast;
  • care of perineum and abdominal incision, if indicated;
  • physical activity and exercise;
  • breastfeeding and infant feeding;
  • resumption of sexual activity;
  • family planning and contraception; and
  • depression and post-partum depression.

State-Mandated Education

Information for Parents of Newborns Requirement

Chapter 161, Health and Safety Code, Subchapter T requires hospitals, birthing centers, physicians, nurse-midwives, and midwives who provide prenatal care to pregnant women during gestation or at delivery to give the woman and the father of the infant or other adult caregiver for the infant with a resource pamphlet that includes information on:

  • postpartum depression;
  • shaken baby syndrome;
  • immunizations;
  • newborn screening;
  • pertussis;
  • and sudden infant death syndrome.  

In addition, document in the client's chart that she received this information. The documentation must be retained for a minimum of five years. It is recommended that the information be given twice, once at the first prenatal visit and again after delivery.
Information for Parents of Newborn:

Information for Parents of Children

Chapter 161, Health and Safety Code, Subchapter T also requires hospitals, birthing centers, physicians, nurse-midwives, and midwives who provide prenatal care during gestation or at delivery to pregnant women on Medicaid to provide the woman and the father of the infant or other adult caregiver for the infant with a resource guide that includes information relating to the development, health and safety of a child from birth until 5 years old. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate childcare.

“A Parent’s Guide to Raising Healthy, Happy Children” is available through Texans Care for Children.

Provision of Information about Umbilical Cord Blood Donation Requirement

Chapter 162, Health and Safety Code, Subtitle H requires that a physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant will give the woman an informational brochure before the third trimester of the woman’s pregnancy, or as soon as reasonably feasible. It should include information about the uses, risks and benefits of cord blood stem cells for a potential recipient, options for future use or storage of cord blood, the medical process used to collect cord blood, any costs that may be incurred by a pregnant woman who chooses to donate or store cord blood after delivery, and average cost of public and private storage.

Resources

Perinatal Dental Services

Providers are expected to follow rules and regulations established by the Dental Practice Act.

See workbook for reimbursable procedure codes.

Prenatal/Post-Partum Dental Services

Provided to pregnant women up to three months post-partum. These include:

  • comprehensive and periodic oral evaluations;
  • radiographs; and
  • preventive and therapeutic dental services.

Space maintainers are designed to prevent tooth movement and may help in the following situations:

  • After premature loss of deciduous or primary tooth first or second molar(s) tooth identification (TID): A, B, I and J for clients who are 1 through 12 years old (procedure codes D1510, D1516).
  • After premature loss of deciduous or primary tooth, first or second molar(s) TID: K, L, S and T for clients who are 1 through 12 years old (procedure codes D1510, D1517).
  • After loss of a permanent first molar(s) (TID: 3 and 14) for clients who are 3 years or older (procedure code D1510).
  • After loss of a permanent first molar(s) (TID: 19 and 30) for clients who are 3 years or older (procedure codes D1510, D1517).

The following age restrictions and limitations will be enforced during quality reviews:

  • D2950 is a benefit for clients 6 years or older.
  • D2952 is a benefit for clients 13 years or older.
  • D3320 and D3330 are benefits for clients 12 years or older.
  • D2933 and D2934 are benefits for primary teeth C through H, M through R only.
  • Direct restoration of a primary tooth through the use of a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pretreatment X-ray images, intra-oral photos and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown (D2930, D2933, D2934).

Initial and Return Perinatal Dental Visit

At the initial dental visit, a medical and dental history must be documented. A history and reason for the visit must be updated at each visit. Dental history must include:

  • history of the present problem;
  • relevant past medical history, including reproductive history and pregnancy status;
  • allergies, sensitivities or reactions to medicines or other substances;
  • current medications, prescriptions, over the counter and complementary and alternative medicines; and
  • use of tobacco and alcohol, including type, duration, frequency and route.

Dental Examination

All dental visits must include an oral examination. Initial and return dental visit must include:

  • limited head and neck examination for the initial visit and as indicated for return visits;
  • assessment and reporting for abuse and neglect (mandated by Texas Family Code, Chapter 261);
  • blood pressure and pulse, as indicated;
  • radiographs and photographs, as indicated;
  • prescription(s), if indicated;
  • treatment plan of care; and
  • procedure(s) and treatment provided.

Perinatal Dental Education and Counseling

Dental nutritional education and counseling is provided by dentists or dental hygienists as it relates to prevention of dental disease and achieving oral health. Therefore, a registered dietician is not eligible to perform these services. Education should include:

  • How to develop positive oral health behavior.
  • How positive oral health behaviors impact the pregnancy and unborn child.
  • Education on proper oral health care for infants and children.
  • Any other education as indicated by history, exam, procedures, treatments or risks.
  • Resource
  • DSHS Oral Health Improvement Program
     

Resource

5400 Child/Adolescent Clinical Guidelines

Revision 22-3; Effective Sept. 30, 2022

Child/Adolescent Services

Services must be provided based on recommendations of the American Academy of Pediatrics (AAP), per the current Texas Health Steps Periodicity Schedule, and as indicated by history, risk assessments or exams through 21 years. See workbook for reimbursable procedure codes.

Well Child and Adolescent History and Risk Assessment

The health history must at least address the following:

  • reason for visit;
  • current health status, including:
    • family medical history;
    • neonatal history for 5 years and younger;
    • physical and mental health history;
    • developmental history;
    • immunization status and history; and
    • nutrition and feeding history;
  • significant history, including:
    • hospitalizations;
    • surgery;
    • biopsies; and
    • blood transfusions and other exposure to blood products;
  • current medications, including prescription, over the counter, and complementary and alternative medicines;
  • allergies, sensitivities or reactions to medicines or other substance(s);
  • exposure or use of tobacco, alcohol and illicit drugs, including type, duration, frequency and route;
  • review of systems;
  • assessment for family violence including a safety assessment when indicated;
  • reproductive health history when appropriate must include:
    • secondary sex characteristics;
    • menstrual history, including last normal menstrual period;
    • sexual behavior history, including:
      • family planning practices;
      • number of partners;
      • gender of sexual partner; and
      • sexual abuse;
    • gynecological and urologic conditions;
    • STDs and HIV risks and exposure; and
    • cervical cancer screening, beginning at 21 years. 

Any pertinent history must be updated at each subsequent visit.

Comprehensive Child and Adolescent Physical Examination

For well child and adolescent visits, a complete physical examination is required at each visit. A comprehensive unclothed physical examination includes all the components listed below. For any portion of the examination that is deferred, document the reason(s) for deferral.

  • Measurements and percentiles, as appropriate, should be documented including:
    • length, height and weight measurements;
    • front-occipital head circumference for 2 years and under;
    • body Mass Index (BMI) beginning at 2 years; and
    • blood pressure beginning at 3 years old.
  • Developmental screening should be completed at checkups from birth through 6 years. Providers should follow the Texas Health Steps Periodicity Schedule and must use one of the following validated, standardized tools found at Developmental and Autism Screening Tools.
  • Mental health screening should be conducted at each checkup using one of the following tools. Providers should follow the Texas Health Steps Periodicity Schedule and must use one of the following validated, standardized tools found at Mental Health Screening Tools.
  • Screening for maternal postpartum depression should be performed at infant checkups up to 12 months. Screening tools can be found in The Texas Clinician’s Postpartum Depression Toolkit. 
  • Sensory screening should include vision acuity and audiometric hearing screening at various ages following the Texas Health Steps Periodicity Schedule.
    • Documentation of test results from a school vision or hearing screening program may replace the required screening if conducted within 12 months of the checkup.
  • Limited oral screening for caries and general health of the teeth and oral mucosa is part of the physical examination. Refer to a dentist at 6 months and every six months thereafter.
  • Age-appropriate immunizations:
    • Vaccines must be administered according to the current Advisory Committee on Immunization Practices (ACIP). Find the ACIP schedule at the CDC Immunization Schedules website.
    • Title V MCH FFS contractors are recommended to become a Texas Vaccines for Children (TVFC) provider. Providers may obtain vaccines free of charge from the Texas Vaccines for Children (TVFC) Program for clients birth through 18 years old. Providers must not charge the client for the vaccines.
  • Nutritional screening or counseling by a licensed dietitian is completed for children with a high-risk condition and for children 3 years and older with an abnormal Body Mass Index (BMI). Nutritional screening must be performed at every visit.
  • Risk screening, including family violence, lead, TB and adolescent lifestyle.
  • Age-appropriate laboratory tests.

Sick Child Visit

Other sources of funding should be used to provide medications for the treatment of acute and minor illness at little or no cost to the patient. A sick child visit includes problem-oriented history, physical exam and lab tests, as indicated by condition.

Resources

Child and Adolescent Visit Laboratory and Other Diagnostic Tests

Contractors can submit all Title V MCH FFS laboratory testing, except for Newborn Hereditary/Metabolic (NBS) testing, to the laboratory of their choice.

Contractors and subcontractors must have a Texas Department of State Health Services (DSHS) laboratory submitter number to submit specimens to the DSHS laboratory.

Contractors submitting non-NBS, Title V-covered laboratory testing to the DSHS laboratory will be charged at the DSHS laboratory’s published fee schedule rate and will be responsible for payment in full.

Agencies must have written plans to address laboratory and other diagnostic tests orders, results and follow-up to include:

  • Tracking and documentation of tests ordered and performed for each client.
  • Tracking test results and documentation in patients’ records.
  • A mechanism to notify patients of results in a manner to ensure confidentiality, privacy and prompt, appropriate follow-up.

Child and Adolescent Laboratory and Diagnostic Tests

Well child/adolescent checkups may include various laboratory tests appropriate to age and risk.

Documented laboratory results within the prior month are acceptable for use for children 2 years and younger and up to 90 days for those 3 years and older.

Well child and adolescent laboratory tests should follow the Texas Health Steps Periodicity Schedule. Tests should be appropriate to age and risk (see Title V workbook for covered lab tests).

Resources

Child and Adolescent Education and Counseling

Patient education must be face to face. Bright Futures literature is preferred, found here. Education and counseling should be based on health history, risk assessment, and physical exam and must cover the following:

  • age appropriate anticipatory guidance including injury prevention, behavior, health promotion and nutrition;
  • child development;
  • immunizations;
  • when and where to obtain emergency care;
  • risk factors identified during the visit;
  • referral to WIC;
  • information on parenting and postpartum counseling, as indicated and mandated by Chapter 161, Health and Safety Code, Subchapter T; and
  • other education and counseling, as indicated.

Child and Adolescent Dental Services

Providers are expected to follow rules and regulations established by the Dental Practice Act, provided to children from birth through 21 years. These include:

  • diagnostic services including comprehensive and periodic oral evaluations and radiographs;
  • preventive services including fluoride treatment and placement of dental sealants to any tooth at risk of dental decay; and
  • therapeutic services including restorative treatment.

See Title V workbook for reimbursable procedure codes.

Restorative treatment is limited. These procedures must be documented as medically necessary and appropriate. For children under 6 months, medically necessary dental services may be provided due to oral trauma early childhood caries, or both.

Space maintainers are designed to prevent tooth movement and may help in the following situations:

  • After premature loss of deciduous or primary tooth first or second molar(s) tooth identification (TID): A, B, I and J for clients who are 1 through 12 years old (procedure codes D1510, D1516).
  • After premature loss of deciduous or primary tooth, first or second molar(s) TID: K, L, S and T for clients who are 1 through 12 years old (procedure codes D1510, D1517).
  • After loss of a permanent first molar(s) (TID: 3 and 14) for clients who are 3 or older (procedure code D1510).
  • After loss of a permanent first molar(s) (TID: 19 and 30) for clients who are 3 years or older (procedure codes D1510, D1517).

The following age restrictions and limitations will be enforced during quality reviews:

  • D2950 is a benefit for clients 6 or older.
  • D2952 is a benefit for clients 13 or older.
  • D3320 and D3330 are benefits for clients 12 or older.
  • D2933 and D2934 are benefits for primary teeth C through H, M through R only.
  • Direct restoration of a primary tooth through the use of a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pretreatment X-ray images, intra-oral photos and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown (D2930, D2933, D2934).

Child and Adolescent Initial or Return Dental Examinations

At the initial dental visit, a medical/dental history must be documented. History and reason for the visit must be updated at each visit. Dental history must include:

  • history of the present problem;
  • relevant past medical history, including reproductive history and pregnancy status;
  • allergies, sensitivities or reactions to medicines or other substances;
  • current medications, prescriptions, over the counter and complementary and alternative medicines; and   
  • use of tobacco and alcohol including type, duration, frequency and route.

Dental Examination

All dental visits must include an oral examination. The initial/return dental visit must include:

  • limited head and neck examination for the initial visit and as indicated for return visits;
  • assessment and reporting for abuse and neglect (mandated by Texas Family Code, Chapter 261);
  • blood pressure and pulse, as indicated;
  • radiographs and photographs, as indicated;
  • prescription(s), if indicated;
  • treatment plan of care; and
  • procedure(s) and treatment provided.

Child and Adolescent Dental Education and Counseling

Dental nutritional education and counseling is provided by dentists or dental hygienists relating to prevention of dental disease and achieving oral health. Therefore, a registered dietician is not eligible to perform these services.

  • How to develop positive oral health behavior.
  • Education on proper oral health care for infants and children.
  • Any other education, as indicated by history, exam, procedures, treatments or risks.

Resources

5500 Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation Orders

Revision 20-0; Effective December 18, 2020

Contractors that provide clinical services must develop and maintain written clinical prescriptive authority agreements, protocols and standing delegation orders in compliance with statutes and rules governing medical, dental, and nursing practice and consistent with national evidence-based clinical guidelines. When HHSC revises a policy, contractors need to incorporate the revised policy into their written procedures.

Prescriptive Authority Agreements (PAAs)

Contractors who delegate the act of prescribing or ordering a drug or device to advanced practice registered nurse(s) (APRNs) and/or physician assistant(s) (PAs) must have in place a PAA, as required by Texas Administrative Code Title 22, Part 9, Chapter 193.

The PAA must meet all the requirements delineated in the Texas Medical Practice Act, Chapter 157, including, but not limited to, the following minimum criteria:

  • Be in writing, signed and dated by the parties to the agreement;
  • Include the name, address and all professional license numbers of all parties to the agreement;
  • State the nature of the practice, practice locations or practice settings;
  • Identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed;
  • Provide a general plan for addressing consultation and referral;
  • Provide a plan for addressing patient emergencies; and
  • Describe the general process for communication and sharing of information between the physician and the APRN or PA to whom the physician has delegated prescriptive authority related to the care and treatment of patients.

If alternate physician supervision is to be utilized, designate one or more alternate physicians who may:

  • Provide appropriate supervision on a temporary basis in accordance with the requirements established by the PAA and the requirements of this section;  
  • Participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; and
  • Describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes the following:
    • Chart review, with the number of charts to be reviewed determined by the physician and APRN or PA; and
    • Periodic face-to-face meetings between the APRN or PA and the physician at a location determined by the physician and the APRN or PA.

Protocols

Contractors that employ APRNs or PAs must have written protocols to delegate authorization to initiate medical aspects of client care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than have two documents, this delegation can now be included in a PAA if both parties agree to do so. The PAA and/or protocols need not describe the exact steps that an APRN or a PA must take with respect to each specific condition, disease or symptom.

The protocols must be reviewed, agreed upon, signed and dated by the supervising physician, and the PA and/or APRN, at least annually and maintained on-site.

Standing Delegation Orders (SDOs)

Contractors that employ unlicensed and licensed personnel, other than APRNs or PAs, whose duties include actions or procedures for a patient population with specific diseases, disorders, health and oral problems or sets of symptoms, must have written SDOs in place. SDOs are instructions, orders, rules, regulations or procedures that specify under what set of conditions and circumstances actions should be instituted. The SDOs delineate under what set of conditions and circumstances a registered nurse (RN), licensed vocational nurse (LVN), dental hygienist, dental assistant or non-licensed health care provider (NLHP), promotor(a) or community health worker may initiate actions or tasks in the clinical setting, and provide authority for use with patients when a physician, dentist, APRN or PA is not on the premises, and/or prior to being examined or evaluated by a physician, dentist, APRN or PA.

SDOs are distinct from specific orders written for a particular patient. The SDOs must be dated and signed by the physician who is responsible for the delivery of medical care covered by the orders. The SDOs must be reviewed and signed at least annually.

Dental Delegation

Contractors must abide by delegation rules set forth by the Dental Practice Act. A licensed dentist may delegate orally or in writing a service, task or procedure to a dental hygienist who is under the supervision and responsibility of the dentist, as specified by the Dental Practice Act. A dentist is not required to be on the premises when the dental hygienist performs a delegated act. A licensed dentist may delegate to a qualified and trained dental assistant acting under the dentist’s general or direct supervision any dental act that is reasonable and a prudent dentist would find is within the scope of sound dental judgment to delegate as specified by the Dental Practice Act. Physical presence does not require that the supervising dentist be in the treatment room when the dental assistant performs the service as long as the dentist is in the dental office/clinic. A delegating dentist is responsible for a dental act performed by the person to whom the dentist delegates the act.

Resources

Requirements addressing the scope of practice and delegation of medical, dental and nursing acts can be accessed at the following websites:  

Relevant Rules