• "Scheduled early due to doctor's appointment schedule." Good only if the date is a few days early.

• "Significant neonatal problems, (mention diagnosis), requiring additional CHDP visit." For an extra newborn visit.

• "Inexperienced young, first time mother" or "Poor mother-infant relationship." For an extra newborn visit.

• "Child not showing normal growth or development, extra CHDP visit necessary." For an extra infant or toddler visit.

• "Exam required for first grade entry."

• "Child in foster care, annual exam."

• "Required exam for sports or camp participation, annual exam."

• "Child with CCS condition, (give diagnosis), needs annual CHDP exam."

Patient Demographics
Fill in all the boxes including a Next Visit return date (excluding the Medical Record No. box). Failure to do so may result in a complete claim denial. For offices that cannot project more than a few months ahead for scheduling appointments, simply add the required interval plus one day between visits to determine the Next Visit return date.

Problem Suspected
When you mark a Problem Suspected box, you must do so with a number from the Follow up Codes box that matches your action and medical record.

All Problem Suspected responses require a comment to be entered into the Comments/Problems section giving the diagnosis and plan. This is not intended to be a medical note, e.g., R/O heart disease, refer to CCS cardiologist.

Referrals
Anytime a child is referred elsewhere, enter a response into the Referred To box, e.g., Susan Smith, DDS or CCS for cardiologist.

ICD-9 Codes
When a problem is identified and a diagnosis is made, enter the ICD-9 Code here.

Screening Failures
If a child fails or cannot perform for the Snellen, audiometric, hemoglobin/hematocrit or urine dipstick and you feel the result is uncertain, mark a 2 under Problem Suspected, New. Then bring the child back, repeat the screen and submit a Screening Procedure Recheck with the previous CHDP exam date referenced in the Comments/Problems section. You will be reimbursed for both screens. This can be done only once. If a child fails the initial and second screen, he/she is to be referred for a specialty evaluation.

Partial Screens
The Partial Screen can never be used to recheck a child who had a problem identified in the History and Physical Examination section. It is intended to cover visits for a hemoglobin/hematocrit screen for WIC, for Immunizations given in between regularly scheduled CHDP visits or for the performance of screening procedures that were not done at a recent full CHDP visit. Reimbursement for Partial Screen visits are always improved by a written explanation in the Comments/Problems section, e.g., "Partial screen for audiometric screen because machine not working on date of previous CHDP visit (enter date)".

Head Circumference
Remember to record the OFC on all children under 2 years in the Comments/Problems section.

Routine Referrals
Check the Blood Lead box whenever the child has a risk factor or is 1 and, again, 2 years old. Check the Dental box for every child at 3 years and above at every CHDP visit. Checking these boxes indicates that you have ordered the lead test or recommended a dental visit for the child. It does not mean you have assumed an obligation to get them done.

Tobacco Questions
The easiest way to lose reimbursement is to not answer these three questions. Don't forget!

Immunizations
For better or worse, there are many types and brands of vaccines. You must use the correct CHDP Code for each one, e.g., DT(a)P has a different code and reimbursement than DTP Dt/Td. The same goes for the hepatitis B variants and combinations. Make sure your biller understands and has a list of the correct codes.

WIC
As a CHDP Provider, you are required to refer families to WIC who may qualify. Don't attempt to figure out if they qualify, assume that any child who qualifies for a CHDP exam may be eligible for WIC and check the WIC referral box. Have a paper with the WIC number and address on it or the County WIC pamphlet for your staff to hand to each parent during the preparation of the child for your visit.

Patient Eligibility
Patients have Medi-Cal or no insurance. Those with no insurance must meet CHDP financial eligibility criteria and fill out the DHS 4073 form. This form must go with the PM 160 for reimbursement. Children with Healthy Families insurance are not eligible for CHDP reimbursable visits.

Signature & Date
This seems obvious but, it is the CHDP Provider who must sign the PM 160. The date must match the Date of Service box above.

Final Comments
The PM 160 is a complicated claim form. Denials are time intensive, (= expensive), to appeal. Therefore, the best option is to have a "final reviewer" in your office whose job is to confirm that each and every PM 160 is completely and properly filled prior to submission for reimbursement.

The PM 160 is not meant to be a medical record of the CHDP visit. Everything that is recorded on the PM 160 should be in the patient's record also. However, keeping your copy is essential if you need to refer to a past CHDP visit.

The CHDP Administrative Office does review PM 160s and may contact the provider to respond to follow up questions on problems identified during a CHDP visit. They may also compare PM 160s with patient records during a provider site visit and chart audit.

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   Mailing Address: County of Santa Cruz  Health Services Agency
   1080 Emeline Avenue, Santa Cruz, CA 95060 | Phone: 831 454 4000 | Fax: 831 454 4770
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