Common Errors in Texas Health Steps (THSteps) Preventative Exams

February 1, 2022

THSteps Guidelines

Blue Cross and Blue Shield of Texas (BCBSTX) conducts quarterly audits of Medicaid (STAR and STAR Kids) Texas Health Steps (THSteps) preventative exams to ensure members are receiving a thorough exam per the THSteps guidelines. The THSteps Periodicity Schedule for Infants, Children, and Adolescents defines the required components of the checkup and closely reflects the Bright Futures/American Academy of Pediatrics schedule of Recommendations for Preventive Pediatric Health Care. Below are some common errors identified in audits performed.

Common Errors Identified in Audits:

Tuberculosis Questionnaire

  • The Tuberculosis Questionnaire should be completed annually beginning at 12 months of age and thereafter at well child exams. A Tuberculin skin test (TST) is to be administered when the screening tool indicates a risk for possible exposure. Please submit the questionnaire or documentation of completion when you are audited to receive credit.

Vital Signs

  • THSteps requires completing height/length and weight on all children of all ages. Starting at the age of 24 months, a Body Mass Index (BMI) is required annually on all children. At the age of three years, documentation of blood pressure is required. If the child is uncooperative or unable to perform the test, document the reason to receive credit.

Lead Risk Assessment

  • In accordance with current federal regulations, THSteps requires documentation of a blood lead screening at ages 12 and 24 months per the THSteps Periodicity Schedule and must be performed during the medical checkup.

Dental Referral

  • Texas Medicaid defines a dental home as the dental provider who supports an ongoing relationship with the client that is inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. In Texas, establishment of a client’s dental home should begin at 6 months of age but no later than 12 months of age and includes referral to dental specialists when appropriate.

The physician must refer clients to establish a dental home beginning at six months of age or earlier if trauma or early childhood caries are identified. For established clients after the six-month medical checkup, the provider must confirm if a dental home has been established and is on-going; if not, additional referrals must be made at subsequent medical checkup visits until the parent or caregiver confirms that a dental home has been established for the client. The parent or caregiver of the client may self-refer for dental care at any age, including 12 months of age or younger.

Screening and Administration of Immunizations

  • Providers must assess the immunization status at every medical checkup to ensure all age requirements have been met. The necessary vaccines and toxoids must be administered at the time of the checkup unless medically contraindicated or because of parent’s or caregiver’s reasons of conscience including religious beliefs. If an indicated vaccine or toxoid was not administered, the reason must be documented in the client’s medical record.

Follow-up for Next Preventative Visit

  • THSteps checkup requires informing members of the next preventative visit. Documentation cannot say “follow-up PRN” or “return in two months”. Examples of adequate documentation include:
    “Follow-up for next preventative exam in …”, “Follow-up for next THSteps checkup in …” or “Follow-up for 5y checkup in one year”.

The Texas Health Steps website offers up-to-date information on periodicity schedules, checkup components, and trainings as resources to providers.


Reference and review the BCBSTX Preventive Care Guidelines (PCGs)Clinical Practice Guidelines (CPGs), and THSteps for Medical Providers  which includes all current vaccine schedules, ImmTrac2 , and other important guidance for treating your patients.


The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations, and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.