Commonly Missed Observations in Texas Health Steps (THSteps) Well Child Exams

THSteps Guidelines

Blue Cross and Blue Shield of Texas (BCBSTX) conducts quarterly audits of Medicaid (STAR and STAR Kids) Texas Health Steps (THSteps) guideline compliance to ensure our members are receiving thorough check ups and well child exams. The THSteps Periodicity Schedule for Infants, Children, and Adolescents defines the required observations 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.

Top 5 Missing Observations Identified in Audits:

Completion of the Questionnaire About Your Child and Tuberculosis with parents of child 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 send the questionnaire or documentation of completion when you are audited to receive credit.

  • THSteps requires physical activity education be provided for members of all ages and documented at every well child checkup to provide information about the benefits of healthy lifestyles and practices, as well as disease prevention.
  • Establishment of a client’s dental home which should begin at 6 months of age but no later than 12 months of age and supports on going relationship with the client and supports:
    • Inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way;
    • Dental referral(s) to dental specialists when appropriate. The parent or caregiver of the client may self-refer for dental care at any age, including 12 months of age or younger.
    • For established clients after the six-month medical checkup, the provider must confirm and document if a dental home has been established and is on-going; if not, additional referrals must be made and documented at subsequent medical checkup visits until the parent or caregiver confirms that a dental home has been established for the client.
  • Providers must screen and assess the administration of 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. 
  • THSteps checkup requires informing members of the next preventative visit. Documentation cannot say “follow-up PRN” or “return in 2 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 offeres up-to-date information on periodicity schedules, checkup observations and trainings are resources to providers.

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