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Title: Section 508.8 - Standards and periodicity.

508.8 Standards and periodicity. (a) Provision of care and services. The periodicity schedule contained in this section and the contents of the C/THP examination generally follow those recommended by the Committee on Standards of Child Health of the American Academy of Pediatrics. Appropriate modifications in the content of the examination can be made according to the attending physician's medical judgment, consistent with the needs of the individual child and current recommended standards of medical practice.

(b) Contents of an examination. Every C/THP examination should include the following as appropriate by age:

(1) Comprehensive health history.

(i) (a) For a new patient, a complete family history, social history, past medical history, and review of body systems must be obtained and recorded.

(b) When obtaining the comprehensive health history of children five years of age or younger, the history must include details of pregnancy, delivery, birth weight and the neonatal period.

(c) When obtaining the comprehensive health history of adolescents, a review of the body systems should also include a history of sexual activity and use of contraception and a menstrual history for females.

(d) For patients whose initial histories have already been recorded by the C/THP provider, the family, social and medical histories may be confined to the period since the histories were last recorded.

(ii) The histories may be obtained initially by health assistants, provided the C/THP provider reviews and supplements the histories at the time the provider conducts his or her examination of the child.

(2) Comprehensive physical examination. The examination of a person eligible for C/THP services must be performed by a licensed physician or by a physician's assistant or registered professional nurse qualified to provide primary care services under a physician's supervision, and is to consist of a systematic examination of all parts of the body, including appropriate neurological, dental, otoscopic and funduscopic examinations and observation of the back for scoliosis. Results of the physical examination must be recorded in the medical record by body regions. Blood pressure measurements must be taken for all children three years of age and older.

(3) Assessment of physical growth and nutritional status. Height and weight for all persons eligible for C/THP services, as well as head circumference for infants, are to be measured and recorded at each examination. Measurements of height and weight through the fifth year of age, and of head circumference through one year of age and again at two years of age, should be plotted on a standard growth chart, which is to be incorporated into the medical record. Plotting of measurements for older children and adolescents is recommended but not required.

(4) Assessment of mental and psychosocial development. (i) For children through five years of age, a detailed developmental history of the infant or child must be obtained and documented in the child's medical record. The history should include information relating to speech, cognitive, emotional, psychosocial and gross and fine motor development. Administration of a standardized (formal) developmental screening test, such as the Denver Developmental Screening Test (DDST) or the abbreviated DDST, is recommended but not required. The child's health status must also be updated at each periodic visit in such a way as to allow for serial evaluation.

(ii) For children 6 to 12 years of age, an assessment of the psychosocial adjustment should include a discussion of school performance and peer and family relationships.

(iii) For adolescents 13 years of age and older, an assessment of the psychosocial adjustment should include a discussion of peer and family relationships, school/job performance, use of drugs, alcohol or tobacco and sexual preparedness and activity.

(5) Vision testing. (i) For children less than three years of age, testing should include the following elements:

(a) Observation of the infant's/child's reaction to an object of interest such as a light or familiar toy for gross indication of vision. Each eye is required to be observed separately.

(b) Motility screening, including gross inspection of the eye to determine the presence of any obvious strabismus, and the cover test, which is especially valuable in patients with a small deviation from the norm.

(ii) For children three years of age and older, testing for visual acuity is to be performed and repeated at each examination and must include a distant visual acuity test, which can be performed using the Snellen letter or Symbol E chart. The use of alternative tests (HOTV or Matching Symbol, Faye Symbol, Allen Pictures) should be considered for those preschoolers who cannot be tested by the Snellen letter or Symbol E chart.

(iii) If a child wears eyeglasses, an assessment regarding the need for optometric reevaluation should be made based on screening the child with eyeglasses and the length of time since the last optometric evaluation.

(6) Hearing testing. (i) For children less than three years of age, infant hearing should be tested grossly by the use of loud noises. Deafness must be seriously suspected if there is a delay in development in speech in the older infant.

(ii) For children three years of age and older, testing which consists of a manually administered, individual, pure-tone conduction screening procedure should be provided at each examination.

(iii) In all instances when hearing impairment is suspected by the medical provider based upon testing or an evaluation of the child's risk of hearing impairment, a prompt referral to an approved speech and hearing center must be made.

(7) Assessment of immunization status and provision of immunizations.

(i) An assessment of the record of immunizations given in the past for diphtheria, pertussis, tetanus, polio, rubella, measles and mumps must be recorded. If the dates of the child's previous immunizations are available, they should be recorded in the child's medical chart. If the immunization history is based on parents' reports, efforts to verify this information must be made. Such efforts must be recorded.

(ii) Persons eligible for C/THP services should be immunized in accordance with the following schedules:

(a) Schedule for children beginning immunization in infancy. Age Vaccines Comments

2 months DTP DTP = diphtheria, tetanus, pertussis.

TOPV TOPV = trivalent oral polio vaccine.

4 months DTP, TOPV 6 months DTP An optional dose of TOPV may be given. 15 months Measles One dose of combined measles/mumps/rubella

Mumps (MMR) vaccine is preferred; a tuberculin

skin test may be administered at the same

Rubella visit. Hib = Haemophilus influenzae type b 18 months DTP disease immunization of children at

TOPV 18 months may be considered in known Hib high-risk groups. 24 months Hib Hib immunization of all children is

recommended at this age. 4-6 years DTP While often referred to as "boosters"

(school TOPV these doses constitute an essential entry) part of the immunization process. 14-16 years Td Td = Tetanus and diphtheria for adults;

repeat every 10 years.

(b) Schedules for children not immunized as infants.

(1) Age 13 months through 6 years. Visit Vaccines Comments 1 DTP MMR may be substituted;

TOPV see comment for visit 2.

One-month interval between visits. 2 Measles MMR should be given at first visit when risk

Mumps of exposure is high; DTP and TOPV may then be Rubella started at second visit and interval between

visits 2 and 3 extended to two months. One-month interval between visits. 3 DTP,TOPV

Two-month interval between visits. 4 DTP An optional dose of TOPV may also be given.

6- to 12-month interval between visits. 5 DTP Interval between visits 4 and 5 may be

extended (e.g., school entry), but not

TOPV shortened. 10-year interval between visits. 6 Td Repeat every 10 years.

The Hib vaccine can be provided any time from 24 months up to five years of age.

(2) Ages 7 years through 20 years. Visit Vaccines Comments 1 Measles One dose of Td and one dose of TOPV may

also be given at this visit if circumstances

Mumps warrant (see simultaneous administration of Rubella* vaccines). One-month interval between visits. 2 Td This visit may be eliminated if first doses

TOPV** of Td and TOPV are given at visit I.

Two-month interval between visits. 3 Td If visit 2 is eliminated, the interval

between visits 1 and 3 must be at least two

TOPV** months. 6- to 12-month interval between

visits. 4 Td Interval between doses 3 and 4 may be

TOPV** extended but not shortened.

10-year interval between visits. 5 Td Repeat every 10 years. -----------------------------------------------------------------------

* FOOTNOTE: Before rubella vaccine is administered to females past menarche, the patient and/or her parent/guardian must be asked if she is pregnant. Pregnant patients must not be given rubella vaccine. If the patient is not pregnant, the theoretical risks to a fetus and the importance of not becoming pregnant for three months following vaccination must be explained to the patient before the vaccine is administered.

** FOOTNOTE: TOPV should not be routinely administered to persons 18 years of age and older. -----------------------------------------------------------------------

(3) Simultaneous administration of vaccines. The simultaneous administration of TOPV and one of the following has been shown to be both safe and effective: MMR, MR, measles, rubella, mumps, DTP, Td. It is also possible to administer TOPV, MMR (or a product containing one or more of its component antigens), and either DTP or Td simultaneously (using different injection sites). This latter practice is warranted if there is doubt that the recipient will return for further doses of vaccine or if an older, seriously under-immunized child must be brought up-to-date quickly (e.g., at the time of school entry). The Hib vaccine can be provided any time between the ages of 24 months and six years.

(4) Interruption of immunization schedule. When a delay between doses does not interfere with final immunity and does not necessitate starting the series over again, regardless of the interval elapsed, the schedule may simply be resumed where it was left off.

(8) Laboratory and other diagnostic tests. If a particular test (e.g., lead screening) is not indicated for a specific age group (or any age group), but the child presents history or symptoms calling for the test's use, the test should be performed.

(i) Tuberculin screening. The assessment for tuberculin risk should be made at each visit, with skin tests performed at age 12-13 months, three years and at each age interval thereafter. A tuberculin test should be administered prior to immunizing a child against measles. If that is not possible, the tuberculin test should be administered simultaneously with the measles vaccine. A tuberculin test should be delayed at least six weeks after the administration of a measles vaccine. Where the child's histories indicate a higher risk of tuberculosis, the test should be administered more frequently.

(ii) If the phenylketonuria (PKU) test was not performed at birth, because, for example, the baby was born out-of-state, the PKU test should be performed at the first C/THP exam (within one month).

(iii) Sickle cell screening. Those who are at risk of sickle cell disease must receive sickle cell screening. If the clinician makes the judgment that the child is not at risk (by ethnicity or previous screening), a statement of the assessment should appear in the child's medical record. Children born in hospitals within New York State after 1975 are assumed to be adequately screened for sickle cell disease. If the child is at risk of sickle cell disease and there is any doubt about previous testing, sickle cell screening should be provided as part of the exam.

(iv) Anemia screening. A test for anemia must be done at age 9-10 months, 23-25 months, 3 years, 4 years, 5 years, 6 years, and repeated routinely at each age interval as set forth in subdivision (f) of this section. High-risk infants under nine months should also be tested. Where the child's histories indicate a higher risk, the test should be administered more frequently.

(v) Lead screening. Lead screening must be performed routinely on all children aged nine months through five years and at other times judged appropriate by the provider. Education for the prevention of lead poisoning should be directed toward the parent at the time the child is first screened and at subsequent visits.

(vi) Venereal disease screening. Adolescents aged 13 years and older must be assessed for the need for serological screening for syphilis, and all sexually active females should be offered a routine gynecological examination, pap smear, gonococcal culture and counseling regarding the prevention of unplanned pregnancies. If the provider is not properly equipped to perform these services, referral to a gynecologist, family planning or obstetrical/gynecological clinic is recommended.

(9) Urine screening. A urinalysis must be performed at age three years and repeated at each age interval set forth in subdivision (f) of this section.

(10) Dental care assessment. All children up to age three should have their mouths examined at each medical evaluation and, where appropriate, should be referred for dental care. All children aged three years and over should be referred to a dentist or a dental program for diagnostic evaluation and necessary treatment, unless the child has been to a dentist in compliance with the C/THP examination schedule as set forth in subdivision (f) of this section.

(11) Diagnosis and treatment follow-up. A summary diagnosis and plan for treatment or referral and follow-up must be recorded in each child's medical record. Diagnostic and treatment services must be given at the time of the C/THP examination, if appropriate. If a finding requires more extensive diagnosis and/or treatment than is immediately available, an appointment for these services must be scheduled within 60 days of the C/THP examination. The referring physician or clinic is responsible for follow-up, and results of the diagnostic evaluation should be documented in the medical records.

(12) Observation for child abuse and neglect. Suspected cases of child abuse and maltreatment must be reported to the New York State Central Register of Child Abuse and Maltreatment pursuant to the provisions of section 413 of the Social Services Law.

(c) Continuity of care. The C/THP provider should be available not only for initial and periodic C/THP examinations, but also for illnessrelated services.

(d) Consultation. Consultation with other medical providers should be obtained when deemed necessary by the C/THP provider.

(e) Referral for further diagnosis and/or treatment. When a C/THP examination reveals abnormal conditions and follow-up care is deemed necessary by the C/THP provider, such care must be provided or arranged. Referral to appropriate providers must be made for services which the C/THP provider does not provide. Identification of a condition requiring further diagnosis or treatment during a C/THP examination must be indicated by completion of the CHAP referral code on the claim form submitted for payment.

(f) The following periodicity schedule will apply to all C/THP examinations: (1) 0-1 year--within 1 month; 2-3 months; 4-5 months; 6-7 months; 9-10 months.

(2) 1-6 years--12-13 months; 14-15 months; 16-19 months; 23-24 months; 3 years; 4 years; 5 years.

(3) 6-21 years--6 years; 8-9 years; 10-11 years; 12-13 years; 14-15 years; 16-17 years; 18-19 years; 20 years.

(g) Nonscheduled examination. When a C/THP examination is requested for a child at an age which does not appear on the periodicity schedule contained in subdivision (f) of this section, the provider should, at a minimum, perform those components of the C/THP examination which are required by the last periodic examination the child should have received.

(h) Incomplete required examination. Submission of a claim for a C/THP examination assumes that the provider has taken responsibility to assure that the examination was complete. If the provider cannot complete a recommended component of the examination at the time of the initial examination, every effort should be made to complete the examination at a date determined to be appropriate by the provider.



VOLUME C (Title 18)