This review will note, per box, where the printed information may be found in Intellect.
CHDP PM 160 REVIEW
There several configurations that must be completed before posting to CHDP.
Procedure: All CHDP Assessment and Immunization procedures are automatically captured and displayed in the patient’s Charges --► CHDP screen based on the:
CHDP Age From and CHDP Age To data configuration.
• Enter the qualifying (designated by Agency) minimum and maximum age in months.
CHDP field drop-down: Click either 'A' for assessment OR click 'I' for immunization.
CHDP Seq: Designate the procedures defined sequence number.
• Determines posting attributes and printing on PM 160
Insurance: It may also be useful to create a separate CHDP insurance.
• Useful for P2 configuration
• Different reporting forms are use designate Form Type
Patient Information
PATIENT NAME
Registration --► Regular --► Patient <Last Name>, <First Name>, <Middle Initial>
MEDICAL RECORD NUMBER
Registration --► Regular --► Patient <Patient Account No.>
L.A. Code
Charges --► CHDP <County>
For Los Angeles County use only
PRE-IMPRINTED FIELD
This field is pre-imprinted with a form
Control number that begins with “94” and ends with either 'J' or 'K.'
BIRTH DATE
Registration --► Regular --► Patient <DOB>
AGE
Intellect computes the age based on Registration --► Regular --► Patient <DOB>
SEX
Registration --► Regular --► Patient <Gender>
NOTE: Sex must be entered exactly as it appears on the Medi-Cal eligibility verification system. If the sex stated on the Medi-Cal eligibility verification system is incorrect, note this in the Comments/ Problems area.
PATIENT’S COUNTY OF RESIDENCE AND CODE
Registration --► Regular --►Patient
Intellect completes the code based on the patient’s address.
TELEPHONE NUMBER
Registration --► Regular --► Patient <Home Phone No.>
NEXT CHDP EXAM
Intellect will compute this based on the DOS
Or the date entered in Charges --► CHDP <Next Visit>
The month and year of the next appointment for children 3 years of age and older
RESPONSIBLE PERSON NAME and ADDRESS
Registration --►Regular --►Patient <Guarantor Name>
Registration --►Regular --►Patient <Address>
Registration --►Regular --►Patient <City>
Registration --►Regular --►Patient <State>
Registration --►Regular --►Patient <Zip Code>
ETHNIC CODE
Registration --►Regular --►Patient <Ethnicity>
DATE OF SERVICE
Charges --►CHDP <DOS>
CHDP Health Assessment Screening Procedures and Codes
COLUMN A No Problem Suspected
Charges --►CHDP <A/B>
Typing an 'A' In this column selects the procedure Intellect will place an 'X' in the indicated column for the appropriate Procedure
COLUMN B Refused, Contraindicated, Not Needed
Charges --►CHDP <A/B>
Typing a 'B' In this column selects the procedure Intellect will place an 'X' in the indicated column for the appropriate Procedure
COLUMN C (New)
Charges --►CHDP <C>
Typing a Follow up Code Number In this column selects the procedure Intellect will place an 'X' in the indicated column for the appropriate Procedure.
Note: if the sequence number of a procedure is '1' then the 'C' Column accepts two follow up codes separated by a comma.
COLUMN D (Known)
Charges --►CHDP <D>
Typing a Follow up Code Number In this column selects the procedure Intellect will place an 'X' in the indicated column for the appropriate Procedure.
Note: if the sequence number of a procedure is '1' then the 'D' Column accepts two follow up codes separated by a comma.
OTHER TESTS
Charges --►CHDP
For any assessment procedure with a sequence number greater than '12.'
Vital Statistics
HEIGHT IN INCHES
Charges --►CHDP <Height>
WEIGHT
Charges --►CHDP <Weight>
BODY MASS INDEX (BMI), PERCENTILE
Intellect will compute the Body Mass Index (BMI) number based on height (inches)
and Percentile weight (pounds) and complete the BODY MASS INDEX (BMI) PERCENTILE
Charges --►CHDP <Height>
Charges --►CHDP <Weight>
BLOOD PRESSURE
Charges --►CHDP <BP Syst>
Charges --►CHDP <BP Diast>
HEMOGLOBIN
Charges --►CHDP <HGB>
HEMATOCRIT
Charges --►CHDP <HCT>
BIRTH WEIGHT
Charges --►CHDP <Birth Weight>
Birth weight should be entered for children younger than 2 years of age.
IMMUNIZATIONS
IMMUNIZATIONS
Charges --►CHDP <A/B>
The name and number of all procedures designated in Utility --► Procedure <CHDP> = 'I'
AND where the patient’s age fall within
Utility --► Procedure < CHDP Age From> and <CHDP Age From>
AND where Charges --►CHDP <A/B> has an entry
Column A. (Now Up to Date for Age)
Charges --►CHDP <A/B>
Typing an 'A' in this column selects the procedure Intellect will place an 'X' in the indicated column for the appropriate Procedure
Column B. (Still Not Up to Date for Age)
Charges --►CHDP <A/B>
Typing an 'B' in this column selects the procedure Intellect will place an 'X' in the indicated column for the appropriate Procedure
Column C. (Already Up to Date for Age)
Charges --►CHDP <A/B>
Typing an 'C' in this column selects the procedure Intellect will place an 'X' in the indicated column for the appropriate Procedure
Column D. (Refused or Contraindicated).
Charges --►CHDP <A/B>
Typing an 'D' in this column selects the procedure Intellect will place an 'X' in the indicated column for the appropriate Procedure
PATIENT VISIT
Charges --►CHDP <Patient Visit>
TYPE OF SCREEN
Charges --►CHDP <Type of Screen>
FEES
Charges --►CHDP
Any procedures designated in Utility --► Procedure <CHDP> = 'I'
AND where the patient’s age fall within
Utility --► Procedure < CHDP Age From> and <CHDP Age From>
AND where Charges --►CHDP <A/B>, <C>, or <D>has an entry.
Fees do not apply to the PM 160 Information Only claim form
TOTAL FEES
Charges --►CHDP
The total charges for all procedures designated in Utility --► Procedure <CHDP> = 'I'
AND where the patient’s age fall within
Utility --► Procedure < CHDP Age From> and <CHDP Age From>
AND where Charges --►CHDP <A/B>, <C>, or <D>has an entry.
Service Location
Provider Number
PLACE OF SERVICE
Utility --►Facility <Facility Code>
Attached Charges --►CHDP <Facility Code>
SIGNATURE OF PROVIDER
Dr or a designated representative must sign and date the PM 160 or PM 160 Information Only claim form. Do not use a signature stamp.
REFERRED TO
Charges --►CHDP <Ref Prv>
For the Utility --► Referring <Referral code> entered in the first field
TELEPHONE NUMBER
Utility --► Referring <Phone No>
REFERRED TO
Charges --►CHDP <Ref Prv>
For the Utility --► Referring <Referral code> entered in the second field
TELEPHONE NUMBER
Utility --► Referring <Phone No>
COMMENTS/PROBLEMS
Charges --►CHDP <Comments/Problems>
Following are examples of information to include when appropriate:
• The reason(s) for performing Medically Necessary Interperiodic Health Assessments (MNIHAs). Required in this field: A comment explaining the reason that a MNIHA service was performed, even if the need for a MNIHA 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 BLOOD LEAD
Charges --►CHDP <Blood Lead>
ROUTINE REFERRALS DENTAL
Charges --►CHDP <Dental>
PATIENT IS A FOSTER CHILD
Charges --►CHDP <Foster Child>
DIAGNOSIS CODES
Charges --►CHDP <ICD9 Code>
THE QUESTIONS BELOW MUST BE ANSWERED
1. Patient is exposed to passive (second-hand) tobacco smoke?
Charges --►CHDP <Passive Smoke>
2. Tobacco used by patient?
Charges --►CHDP <Tobacco Use>
3. Patient counseled about/referred for tobacco use prevention/cessation?
Charges --►CHDP <Counseled>
WIC Status
Charges --►CHDP <WIC Referral>
Infants and children under age five, pregnant women at nutritional or medical risk, and women up to six months postpartum or breast-feeding an infant under twelve months of age may be eligible for the Women, Infants, and Children (WIC) Supplemental Food Program.
PARTIAL SCREEN
Charges --►CHDP <Screening>
SCREENING PROCEDURE RECHECK
Charges --►CHDP <Screening>
ACCOMPANIES PRIOR PM 160 DATED
Charges --►CHDP <Prior Pm 160 Dated>
PATIENT ELIGIBILITY (STANDARD PM 160)
COUNTY
Registration --►Regular --►Patient
Intellect completes based on the patient’s address.
AID
Charges --►CHDP <Aid>
IDENTIFICATION NUMBER
Registration --►Regular --►Patient --►Insurance <Subscriber No.>
For the insurance billed Charges --►CHDP <Insurance>
PATIENT ELIGIBILITY (Check Boxes)
Charges --►CHDP <Pt Elig>