5000, Clinical Guidelines

Body

Revision 23-2; Effective Sept. 8, 2023

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

5100 General Consent

Revision 25-3; Effective Sept. 1, 2025

Grantees must get 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 a client does not receive services for a period of three years or more, 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 enough for routine treatment provided through telemedicine. To record a client’s verbal consent, the staff person who obtains the consent must read the consent form to the applicant and document that the applicant affirms by giving their verbal consent for treatment. The document must include the date and time of the applicant’s consent and the signature of the staff person who obtained 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 an understandable manner. 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, unless legally incapable of doing so, such as a minor or a person with a development disability. In such cases, a parent, legal guardian or caregiver must consent on their behalf. Consent must never be obtained in a manner that could be perceived as coercive.

Grantees 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 and must comply with the Texas Administrative Code, State Board of Dental Examiners, Section 108.7, Minimum Standards of Care.

Texas Medical Disclosure Panel Consent

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

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

The grantee is responsible for assuring that informed consent is obtained from the client for procedures per TMDP. TMDP has developed List A, which is informed consent that requires full and specific disclosure for certain procedures.

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

  • are inherent to the procedure, which means one that exists in and is inseparable from the procedure itself; and
  • are material that could influence a reasonable person to decide if they should 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 younger than 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 per the funding source that subsidizes the services. The department and providers may provide pregnancy testing, HIV testing, sexually transmitted infection (STI) testing and treatment for an STI, 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, grantees must comply with Texas Health and Safety Code:

5200 Clinical Policy

Revision 25-3; Effective Sept. 1, 2025

Telemedicine

Providers may provide services by telemedicine if appropriate.

Providers that offer telemedicine services must follow all rules of the Texas Occupations Code, Chapter 111 and must have written policies and procedures for:

  • obtaining informed consent,
  • maintaining confidentiality of the client’s clinical information,
  • ensuring appropriate, quality care,
  • preventing abuse and fraud in the use of telemedicine services,
  • ensuring adequate supervision of health professionals who are not physicians and who providing telemedicine care, and
  • establishing the maximum number of health professionals that a physician may supervise through telemedicine services.

Client Health Records and Documentation of Encounters

Providers must ensure that a client health record is established for every person who receives clinical services and must meet the requirements of the TAC, Texas Medical Board, General Documentation Provisions Rule.

All client 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 and title of the provider, 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 list of all allergies and adverse reactions to medications, food and environmental substances such as latex, including specifying when a client has no known allergies,
  • this information should be prominently displayed in the client’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 to document the reason for the visit, relevant history, physical exam findings, and pertinent screening and diagnostic tests with results and a treatment plan.

Case Management

Grantees must provide case management services on an as-needed basis to clients who require help accessing community resources.

Grantees must refer clients to other resources for assistance with community services they determine necessary but don’t provide. Referrals and case management services must be documented in the clinical record.

Referral and Follow-Up

Grantees 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.

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

  • transmit client’s information — with client’s consent — to the referral resource while maintaining confidentiality and adhering to HIPAA regulations,
  • advise the client about her or his responsibility to comply with the referral,
  • follow up to determine if the referral was completed, and
  • document the outcome of the referral.

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

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

5300 Perinatal Clinical Guidelines

Revision 25-3; Effective Sept. 1, 2025

Perinatal Services

Provide prenatal and postpartum services based on American College of Obstetricians and Gynecologists (ACOG) guidelines. Perinatal visits include medical history, physical examination, laboratory and diagnostic testing, and education and counseling.  

Grantees may bill TVFFS for allowable services provided in clinical prenatal care visits for women during the CHIP-Perinatal or Medicaid for Pregnant Women enrollment process. Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

Medically necessary postpartum visits are reimbursable and include interval history, physical examination, assessment, family planning, counseling, education and referrals as indicated.

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. Grantees must have written plans to address laboratory and other diagnostic test orders, results and follow-up to include:

  • tracking and documenting tests ordered and performed for each client,
  • tracking and documenting test results in client records, and
  • a mechanism to address abnormal results, facilitate continuity of care and assure confidentiality that adheres to HIPAA regulations by making results and interventions accessible to the delivering hospital, facility or provider.

Ultrasounds

Obstetrical ultrasounds will be reimbursed as recommended by ACOG guidelines.

  • Complete ultrasound – A complete evaluation of the pregnant uterus, performed between 18 and 22 weeks’ gestation, to include fetal number, viability, presentation, dating measurements, complete anatomical survey, placental localization and characterizations, and amniotic fluid assessment.
  • Limited ultrasound – A brief, more limited evaluation to determine the number of fetuses, viability, presentation, dating measurements, limited anatomic assessment, placental location and characterization, and amniotic fluid assessment.

Non-Stress Test (NST)

Perform fetal assessment as medically necessary and may be billed as often as the provider deems the procedure to be medically necessary.

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

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. It may be done when results of other tests are non-reassuring.

Perinatal Education and Counseling Services

Grantees must have written plans for client education that include goals and content outlines to ensure consistency and accuracy of information provided. Education must be appropriate to client’s age, level of knowledge and background, and be presented in an unbiased manner.

Depression and Anxiety Screening

ACOG recommends all perinatal clients be screened for depression and anxiety symptoms with a standardized, validated tool at the first obstetric visit, at 24-28 weeks gestation, and at the comprehensive postpartum visit. For ease of administration in obstetric practices, Lifeline for Moms created a composite screener, with separate screeners for both the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9). Both screeners include the Mood Disorder Questionnaire (MDQ), General Anxiety Disorder (GAD-7), and Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). Another safety screener is available to assess suicide risk.

Tobacco Assessment and Quit Line Referral

All women who receive prenatal services should be assessed for tobacco use. Refer women who use tobacco to tobacco quit lines. The Texas Tobacco Quitline provides confidential, free and convenient smoking cessation services to Texas residents 13 years and older, including quit coaching and nicotine replacement therapy. Services can be accessed by phone at 877-937-7848 (877-YES-QUIT) or online at YesQuit.org. The assessment and referral should be performed by agency staff and documented in the clinical record.

Substance Use Disorder Screening, Brief Intervention and Referral to Treatment

All women who receive prenatal services should be screened for substance use disorder through screening, brief intervention, and referral to treatment (SBIRT). Routine screening should be done at the first comprehensive prenatal visit and should use a validated screening tool such as 4Ps, 5Ps, NIDA Quick Screen, CRAFFT, T-ACE, ASSIST and TWEAK.

SBIRT and mental health resources:

Nutrition Counseling

Nutritional counseling by a licensed dietitian is not billable to TVFFS. Clients may be referred to Women, Infants and Children (WIC) for nutritional counseling.

5310 State-Mandated Education

Revision 25-3; Effective Sept. 1, 2025

Information for Parents of Newborns

Health and Safety Code, Subchapter Section T, 161.501 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 infant's father or other adult caregiver Information for Parents of Newborns (PDF). This guide includes information about immunization, newborn screening, postpartum depression and shaken baby syndrome.

Grantees must document in the client’s chart that they 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.

A Parent’s Guide to Raising Healthy, Happy Children

A Parent’s Guide to Raising Healthy, Happy Children (PDF) is designed for parents and adult caregivers of children. The guide provides information about the development, health and safety of children from birth to 5 years.

Provision of Information about Umbilical Cord Blood Donation Requirement

Health and Safety Code, Subtitle H, Section 162.018 requires a physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant to give the woman an informational brochure:

  • before the third trimester of the woman’s pregnancy, or
  • as soon as possible.

The brochure 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.

An Umbilical Cord Blood Banking and Donation Brochure is available through DSHS.

Resources

5320 Initial Prenatal Visit Requirements

Revision 25-3; Effective Sept. 1, 2025

Comprehensive Medical History – Initial Visit

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

  • 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 history 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 activity history, including:
      • family planning practices;
      • number of partners;
      • sex of  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, including living arrangements;
    • family dynamics with assessment for family violence including safety assessment, when indicated which is 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:
      • diabetes;
      • heart disease;
      • intimate partner violence; and
      • injury or malignancy; and
  • systems review documenting pertinent positives and negatives in the health record.

Physical Examination – Initial Visit

For any part of the examination that is deferred, document the reason(s) for deferral in the client health record.

  • 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 per Chapter 167A of the Health and Safety Code;
  • fetal heart rate for gestational age more than 12 weeks; and
  • other systems, as indicated by history and the health risk assessment.

Laboratory and Diagnostic Tests – Initial Visit

Perform lab tests as recommended by accepted standards of care for client’s weeks of gestation or as indicated by risk assessment, history or physical exam. Review Monthly Reporting Packet (MRP) for covered lab tests.

The following tests are state-mandated:

  • Hepatitis B Antigen (HbsAg), mandated by Health and Safety Code 81.090.
  • HIV, unless declined by client, who must then be referred to anonymous testing, mandated by Health and Safety Code 81.090.
  • Syphilis serology, mandated by Health and Safety Code 81.090.

Education – Initial Visit

Base client education on history, risk assessment and physical exam. It must cover:

  • nutrition and weight gain;
  • physical activity and exercise;
  • sexual activity;
  • environmental or work hazards;
  • travel;
  • alcohol use and substance abuse;
  • when and where to get emergency care;
  • anticipated course of prenatal care, including prenatal testing;
  • injury prevention, including seat belt use;
  • cocooning infants and children against pertussis including 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. 

5330 Return Prenatal Visits Requirements

Revision 25-3; Effective Sept. 1, 2025

Interval Medical History – Return Visit

Interval history, including:

  • symptoms of infections;
  • symptoms of preterm labor;
  • headaches or visual changes;
  • fetal movement at more than18 weeks;
  • family violence screening when client is more than 28 weeks; and
  • intimate partner violence assessment at least once each trimester;

Physical Exam – Return Visit

For any portion of the examination that is deferred, document the reason(s) for deferral in the client health record.

  • 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 shown by history or other findings.

Laboratory and Diagnostic Tests – Return Visit

Perform lab tests as recommended by accepted standards of care for client’s weeks of gestation, those mandated by law, and indicated by risk assessment, history or exam. Review Monthly Reporting Packet (MRP) for covered lab tests. 

Return Prenatal Visit Education

Education should be appropriate to weeks of 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);
  • breastfeeding;
  • selecting a provider for the infant; and
  • postpartum family planning.

5340 Postpartum Visits Requirements

Revision 25-3; Effective Sept. 1, 2025

Interval Medical History – Postpartum Visit

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 (PDF);
  • intimate partner violence assessment; and
  • family planning and contraception including current method or future plans;

Postpartum Visit Physical Exam

Document the reason(s) for deferral in the client health record, for any portion of the examination that is deferred.

  • weight;
  • blood pressure evaluation;
  • breast and axilla exam;
  • abdomen exam;
  • pelvic exam, including uterine size per Chapter 167A of the Health and Safety Code; and
  • systems indicated by history or risk profile and other findings.

Laboratory and Diagnostic Tests – Postpartum Visit

Perform lab tests as recommended by accepted standards of care for client’s weeks of gestation, those mandated by law, and indicated by risk assessment, history or exam. Review Monthly Reporting Packet (MRP) for covered lab tests.

Education - Postpartum Visit 

Client 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.

5350 Perinatal Dental Services

Revision 25-3; Effective Sept. 1, 2025

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

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

Perinatal dental services are provided to pregnant women through three months post-partum. These include:

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

Procedure Code Limitations

Space maintainers are designed to prevent tooth movement and may help after premature loss of a deciduous primary first or second molar(s) in the following situations:

  • TID: A, B, I and J- for clients who are 1 through 12 years old using procedure codes D1510 and D1516.
  • TID: K, L, S and T - for clients who are 1 through 12 years old using procedure codes D1510 and D1517. 

The following procedure codes have age restrictions and limitations:

  • D2950 Not allowed on primary teeth; restricted to ages 4 and older
  • D2952 Not allowed on primary teeth; restricted to ages 13 and older and not payable with D2950
  • D3310, D3320 and D3330 Restricted to 6 and older, reimbursement for a root canal includes all appointments necessary to complete the treatment
  • D2933 and D2934 are benefits for anterior primary teeth only (TID C- H and M R
  • Direct restoration of a primary tooth with the use of a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown (D2930, D2933, D2934).

Perinatal Dental Visit History

Document a medical and dental history at the initial dental visit. Update a history and reason for the visit 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; 
  • use of tobacco and alcohol, including type, duration, frequency and route; and
  • screening and reporting, if indicated, for abuse and neglect per Texas Family Code, Chapter 261.

Perinatal 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;
  • 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 education and counseling is provided by dentists or dental hygienists as it relates to prevention of dental disease and achieving oral health. Education should include:

  • oral hygiene instruction;
  • healthier eating and drinking habits to reduce the risk of tooth decay;
  • safety of dental treatment while pregnant;
  • impact of the mother’s oral health on the pregnancy and infant;
  • oral hygiene for infants and children; and
  • individualized education based on history, exam, procedures or risks.

Resource

5400 Child and Adolescent Clinical Guidelines

Revision 25-3; Effective Sept. 1, 2025

Child and Adolescent Services

Provide services based on recommendations of the American Academy of Pediatrics (AAP), Texas Health Steps Checkup Components (PDF) and the Texas Health Steps Periodicity Schedule. All staff who perform child health exams must have completed the online Texas Health Steps module Texas Health Steps: Overview.

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes. Grantees may not bill for a Texas Health Steps medical checkup until all required components are completed. Only one visit may be billed per day, per client. If a client returns on a different day to complete required components of a Texas Health Steps exam, an additional visit may not be charged.

Well Child and Adolescent History and Risk Assessment

A new client initial health history must be retained in the medical record for reference at future checkups and does not need to be repeated at subsequent checkups. It must include the following:

  • If less than five years old, history related to pregnancy, delivery and neonatal conditions
  • Family medical history
  • Personal medical history

Established client interval health history must include:

  • reason for visit,
  • current health status, including any changes in personal health history,
  • current medications, including prescription, over-the-counter, and complementary and alternative medicines,
  • allergies, sensitivities or reactions to medicines or other substance(s),
  • exposure to 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:
    • menstrual history, including last normal menstrual period,
    • sexual behavior history, including:
      • family planning practices,
      • sexual abuse,
    • gynecological and urologic conditions,
    • STIs and HIV risks and exposure, and
    • cervical cancer screening beginning at 21 years. 

Comprehensive Child and Adolescent Physical Examination

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

  • Comprehensive unclothed exam including secondary sex characteristics.
  • Measurements and percentiles, as appropriate, should document:
    • length, height and weight measurements,
    • frontal-occipital head circumference for 2 years and younger,
    • body mass index (BMI) beginning at 2 years, and
    • blood pressure beginning at 3 years.
  • Screening, as appropriate, should document:
    • Complete developmental screening at checkups from birth through 6 years. Providers should follow the Texas Health Steps Periodicity Schedule (PDF) and must use one of the following validated, standardized tools at Developmental and Autism Screening Tools.
    • Conduct mental health screening at each checkup using one of the following tools. Providers should follow the Texas Health Steps Periodicity Schedule (PDF) and must use one of the following validated, standardized tools at Mental Health Screening Tools.
    • Perform screening for maternal postpartum depression at infant checkups up to 12 months. Find screening tools in The Texas Clinician’s Postpartum Depression Toolkit (PDF). 
    • 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 after.
    • 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 BMI. Nutritional screening must be performed at every visit.
    • Risk screening, including family violence, lead, tuberculosis and adolescent lifestyle.
  • Age-appropriate immunizations
  • Age-appropriate laboratory tests
    • Well child and adolescent laboratory tests should follow the Texas Health Steps Periodicity Schedule. Tests should be appropriate to age and risk. Review TVFFS MRP for covered lab tests.
    • Documented laboratory results within the past month are acceptable for use for children 2 years and younger and up to 90 days for those 3 years and older.

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 client. A sick child visit includes problem-oriented history, physical exam and lab tests as indicated by condition.

Resources

Child and Adolescent Laboratory and Other Diagnostic Tests

Grantees can submit all TVFFS laboratory testing to the laboratory of their choice, with the exception of Newborn Screening (NBS) Tests. NBS Tests must be submitted to the Texas Department of State Health Services (DSHS) laboratory.

Grantees and subrecipients must have a DSHS laboratory submitter number to submit specimens to the laboratory.

Laboratory specimens sent to the DSHS laboratory will be charged at the DSHS laboratory’s published fee schedule rate.

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 client’s records.
  • A mechanism to notify clients of results in a manner to ensure confidentiality, privacy and prompt, appropriate follow-up.

Resources

Child and Adolescent Education and Counseling

  • Health education and counseling must be provided at each checkup and documentation must include the time period recommended before the next appointment. 
  • Base education and counseling on health history, risk assessment and physical exam, and must cover the following:

5410 Child and Adolescent Dental Services

Revision 25-3; Effective Sept. 1, 2025

Providers must 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.

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

For children younger than 6 months, medically necessary dental services may be provided because of oral trauma, early childhood caries or both.

Procedure Code Limitations

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

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

The following procedure codes have age restrictions and limitations:

  • D2950 is not allowed on primary teeth. Is restricted to 4 and older.
  • D2952 is not allowed on primary teeth. Is restricted to 13 and older and is not payable with D2950.
  • D3310, D3320 and D3330 is restricted to 6 and older. Reimbursement for a root canal includes all appointments necessary to complete the treatment.
  • D2933 and D2934 are benefits for anterior primary teeth only (TID C-H, M-R).
  • Direct restoration of a primary tooth with a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pre-treatment 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 History

Document medical and dental history at the first dental visit. 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 pregnancy status, as applicable,
  • allergies, sensitivities or reactions to medicines or other substances,
  • current medications, prescriptions and over the counter, complementary and alternative medicines,
  • use of tobacco and alcohol including type, duration, frequency and route, and
  • screening for abuse and neglect and reporting, if indicated as mandated by Texas Family Code, Chapter 261.

Child and Adolescent Dental Examination

All dental visits must include an oral exam. The initial or return dental visit must include:

  • limited head and neck exam for the initial visit and as indicated for return visits,
  • 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 education and counseling is provided by dentists or dental hygienists for the prevention of dental disease and achieving oral health. Education should include: 

  • oral hygiene instruction,
  • healthier eating and drinking habits to reduce the risk of tooth decay, and
  • individual education based on history, exam, procedures or risks.

Resources

5500 Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation Orders

Revision 25-3; Effective Sept. 1, 2025

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

Prescriptive Authority Agreements (PAAs)

When services are provided by an advanced practice registered nurse (APRN) or physician assistant (PA), the grantee must make sure a properly executed PAA is in place for each mid-level provider. The PAA must meet all the requirements delineated in Texas Occupations Code, Chapter 157, including the following criteria:

  • be in writing and signed and dated by the parties to the agreement,
  • be reviewed at least annually, including amendments,
  • kept on-site where the APRN or PA provides care,
  • include the name, address and all professional license numbers of all parties to the agreement,
  • state the nature of the practice, locations or settings,
  • identify the types or categories of drugs or devices that may or may not be prescribed,
  • provide a general plan to address consultation and referral,
  • provide a plan to address client emergencies,
  • describe the general process for communication and information sharing between the physician and the APRN or PA the physician has delegated prescriptive authority related to the care and treatment of people,
  • if alternate physician supervision will be used, appoint one or more alternate physicians who may:
    • provide appropriate temporary supervision that follows the requirements established by the PAA and of this section, and
    • participate in the prescriptive authority quality assurance and improvement plan meetings required under this section,
  • describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes:
    • chart review, with the number of charts to be reviewed determined by the physician and APRN or PA, and
    • periodic meetings between the APRN or PA and the physician at a location determined by the physician, APRN or PA.

References

Protocols

Grantees 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 be included in a PAA if both parties agree to it. The protocols do not need to describe the exact steps an APRN or a PA must take for each specific condition, disease or symptom.

The supervising physician and the PA or APRN must review, agree on, sign and date the protocol at least annually. They must be maintained on-site per Texas Administrative Code, Title 22, Part 9, Chapter 169, Subchapter A

Standing Delegation Orders (SDOs)

SDOs are written instructions, orders, rules or procedures designed for a patient population with specific diseases, disorders, health problems or sets of symptoms. This type of order provides a general set of conditions and circumstances when action can be instituted before being examined or evaluated by a physician. Clinics must have written SDOs in place as outlined in TAC Title 22, Part 9, Chapter 169, Subchapter A.

Standing delegation orders may permit the administration or provision of the following types of drugs if specifically ordered by or using a pre-signed prescription from the delegating physician:

  • oral contraceptives,
  • diaphragms and contraceptive creams and jellies,
  • topical anti-infectives for vaginal use,
  • oral anti-parasitic drugs for treatment of pinworms,
  • topical anti-parasitic drugs,
  • antibiotic drugs for treatment of venereal disease, or
  • immunizations.

General standards for Standing Delegation Orders, Standing Medical Orders and Protocols require:

  • development and approval by the delegating physician or following facility bylaws and policies,
  • the order or protocol must be in writing and signed by the delegating physician,
  • a description of the specific instructions, orders, protocols or procedures to be followed,
  • a notation of the level of supervision required, unless specified by other law,
  • plans to address patient emergencies,
  • annual review signed by the delegating physician, and
  • maintenance at the facility or practice site.

Dental Delegation

Grantees must abide by delegation rules set forth by the Dental Practice Act and Texas State Board of Dental Examiners Rules. A licensed dentist may delegate verbally or in writing a service, task or procedure to a dental hygienist under the supervision and responsibility of the dentist, per 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 specified by the Dental Practice Act. Physical presence does not require the supervising dentist be in the treatment room when the dental assistant performs the service if the dentist is in the dental office or clinic. A delegating dentist is responsible for a dental act performed by the person the dentist delegates the act.

References