Signature of Provider                  SIGNATURE OF PROVIDER.  You or a designated representative must sign and date the PM 160 or PM 160 Information Only claim form.  Do not use a signature stamp.

Referrals to Other                       REFERRED TO and TELEPHONE NUMBER.  When referrals are

Providers                                     made to other providers, enter the name and telephone number of the other provider or agency (when this information is available).

If the patient is referred to more than two providers, enter the additional provider name or agency and telephone number in the Comments/Problems area.

Comments or Problems              COMMENTS/PROBLEMS.  Use this space for remarks that clarify the results of the health assessment and communicate issues to the local and State CHDP programs.

Following are examples of information to include when appropriate:

•  The reason(s) for performing Medically Necessary Interperiodic Health Assessments (MNIHAs).

was identified at the time of the Gateway transaction.

•  Diagnosis and related IDC-9 code, if a diagnosis is made during the visit.

•  Explanation of suspected problems; for example, the nature of a dental problem. Identify dental problems using the “Classification of Dental Treatment Needs,” Classes II–IV.  See the American Dental Association’s “Classification of Treatment Needs” in the Appendix of this manual.

•  Identify whether a patient 3 years of age or older is receiving (or the last time received) dental care.

•  Explain when a procedure is not performed when the procedure is listed as recommended for age.  (See the Periodicity Schedule for Health Assessment Requirements by Age Groups table in the Appendix of this manual).  This includes tests that are performed at an age younger than the age specified.

•  Record the screening procedure code and the name and telephone number of the referred provider when more than two referrals are made.

•  Document the head circumference measurement for children 2 years of age or younger. Record measurements to one-fourth (1/4) inch.

•  Results of vision test.

•  Results of blood lead tests, when known.

•  Primary language of the patient or guardian if other than English.

•  Patient did not return for the reading of a Tuberculin (TB) test.

•  Note discrepancies between known information and information provided by the eligibility verification system; for example, gender.

•  Mother’s Medi-Cal identification number is being used to bill for services rendered to an infant during the birth month or the month following.

•  The reason for extra time spent with the patient when billing for an “Extended Visit” for other than new patients or patients not assessed within the last two years.

•  Immunization administered because individual is in a high-risk category.

•  Elevated blood lead levels.

•  Results of blood glucose test and whether the results are within normal limits.

•  Results of cholesterol test and whether the results are within normal limits.

Routine Referrals                         ROUTINE REFERRALS.

BLOOD LEAD. Enter a check mark (a) in this box when a child has been referred to a laboratory for the collection of a blood specimen for the lead test.

DENTAL. Enter a check mark (a) in this box only when no dental problem is suspected, but you have advised the parents to obtain the annual preventive dental care for a Medi-Cal child. Annual referrals begin at age 3 or earlier, if necessary, for maintenance of dental health.

Foster Child Indicator                  PATIENT IS A FOSTER CHILD.  Enter a check mark (a) when the patient is in a foster care home or has been placed with a relative by the county welfare department.

Diagnosis Codes                         DIAGNOSIS CODES.  Enter the International Classification of Diseases code in the Diagnosis Codes area for each condition or problem suspected. Do not leave blank spaces in the boxes.

If the diagnosis code is fewer than five numbers, enter zeros in the last (right) spaces of the box.  For example, ICD-9-CM code 034 (strep throat) is entered as 03400 and ICD-9-CM code 493.9 (asthma, unspecified) is entered as 49390.

Tobacco Prevention/                   THE QUESTIONS BELOW MUST BE ANSWERED.  Enter patient’s

Cessation Questions                   response to the questions concerning smoking.  (Refer to the CHDP Health Assessment Guidelines for “Protocol for Anti-Tobacco Health Education”).

                                                          1. Patient is exposed to passive (second-hand) tobacco smoke?

                                                          2. Tobacco used by patient?

                                                          3. Patient counseled about/referred for tobacco use prevention/cessation?

WIC Status                                   ENROLLED IN WIC.  Infants and children younger than 5 years of age, pregnant women at nutritional or medical risk, and women up to six months postpartum or breast feeding an infant younger than 12 months of age may be eligible for the Women, Infants, and Children (WIC) Supplemental Nutrition Program.

If the patient is already enrolled in WIC, enter an “X” in Enrolled in WIC (Box 1).

If you are making a referral to the WIC Program, enter an “X” in Referred to WIC (Box 2).

WIC requires that height, weight, hemoglobin and hematocrit values be entered.

.

Note:  Specify in the Comments/Problems area whether you are requesting CHDP staff assistance to refer a family to WIC.

Call your local CHDP program to receive information about the WIC program.

Partial Screens                            PARTIAL SCREEN.  Complete the partial screening procedure and enter the information on the PM 160 as follows:

•  Enter the patient and provider identifying information

•  Enter a check mark (a) in Column A or a numeric follow-up code in Column C or D for the procedure given

•  Enter the appropriate remarks, such as justification of the partial screen, tests, etc., in the Comments/Problems area

•  If immunization services were rendered, enter the code number of the immunization, and complete Column A or B

•  Enter the date of service

•  Enter a check mark (a) in the Partial Screen box

•  Enter the date of the complete CHDP health assessment from the prior PM 160 or the future date of the CHDP health assessment in the Accompanies Prior PM 160 Dated area

•  Enter the “Patient Eligibility” information

•  Enter “ Fee(s)”

•  Enter “Total Fees”

For general information about partial screens, refer to “Partial Screens” in the Child Health and Disability Prevention (CHDP) Program:  Billing and Reimbursement section of this manual.

Recheck of                                   SCREENING PROCEDURE RECHECK.  Complete the screening

Screening Procedure                  procedure recheck and enter the information as follows:

•  Enter patient and provider identifying information

•  Enter a check mark (a) in column A, or a numeric follow-up code in column C or D for the outcome of the screening procedure(s) being performed

•  Enter appropriate remarks, such as justification for screening procedure recheck, test results, etc., in the Comments/ Problems area

•  Enter a check mark (a) in the Screening Procedure Recheck box

•  Enter the date of service

•  Enter the date of service from the prior PM 160 in the in the Accompanies Prior PM 160 Dated area

•  Enter the “Patient Eligibility” information

•  Enter “ Fee(s)”

•  Enter “Total Fees”

Note:  Only screening procedures 06 through 20 and 22 may be submitted for reimbursement as rechecks.

For general information about rechecks, refer to “Recheck of Screening Procedure” in the Child Health and Disability Prevention (CHDP) Program:  Billing and Reimbursement section of this manual.

ACCOMPANIES PRIOR PM 160 DATED.  Enter the date of the complete CHDP health assessment from the prior PM 160 or the future date of the health exam appointment in the Accompanies Prior PM 160 Dated area.

Patient Eligibility:                        PATIENT ELIGIBILITY (STANDARD PM 160).  Patient eligibility

Standard PM 160                         information on the standard PM 160 is completed as follows:

•  COUNTY.  Enter patient’s two-digit county code (obtained when eligibility verification is performed).

•  AID.  Enter patient’s two-digit aid code (obtained when eligibility verification is performed).

•  IDENTIFICATION NUMBER.  Enter patient’s identification number from the plastic Benefits Identification Card (BIC) or Immediate Need Eligibility Document.

•  If the patient is covered (a) by Medi-Cal or is pre-enrolled in Medi-Cal through the CHDP Gateway, enter a BIC number as above.  Ensure that a check mark (a) appears in box 1.

Mother’s Medi-Cal                        A mother’s Medi-Cal identification number may be used to

Identification Number                  bill for services provided to an infant during the infant’s month of birth and the month immediately following.

Patient Eligibility:                        PATIENT ELIGIBILITY (PM 160 INFORMATION ONLY).  Patient

PM 160 Information-Only            eligibility information on the PM 160 Information Only claim form is completed the same as for the standard PM 160, except there are no separate boxes to check.

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