From Well Baby to Geriatric Assessments Creating Value Before You Identify a Problem Documentation that insurers will pay for

Learning Objectives What the frame of a Preventive Service visit includes & excludes What insurers want to see documented Content of GTFC Preventive Service paper templates How to document Preventive Services in ezSOAP Documentation of “separate identifiable services” Practice over next month

Defining Preventive Services Age/gender specific history & exam to detect asymptomatic disease Counseling for all recommended screening tests and immunizations – order/referral if appropriate Review of Symptoms Monitoring of controlled conditions that do not require additional service, e.g. Mild osteoarthritis doing well with regular exercise and acetaminophen Identification, patient education, and plan for newly recognized “insignificant or trivial” problems not requiring additional work Counseling for risk reduction

Defining “Separate Identifiable Services” “significant enough to require additional work to perform the key components of... an E/M service” Examples Detection of new problem requiring Rx Evaluation of new problem requiring testing (not included in age/gender preventive services) & follow up Renewal of Rxes for chronic condition(s) at target Change of Rxes for chronic condition not at target

What to document? Visit if for purpose of primary prevention – even if that is not the first CC patient gives! Status of all recommended services – all that are “due” are either done, counseled for, or ordered ROS, PFSH update Age/gender exam to detect asymptomatic disease List of insignificant and trivial diagnoses as well as chronic at target diagnoses Counseling done Plan for F/U of other important conditions

What do we use at GTFC? Missouri’s “Healthy Children & Youth Screening Guide” Expert Panel – doesn’t distinguish strength of evidence Supplemented by “Denver PDQ” developmental screens through age 5 Must be used for all Missouri Medicaid patients per age Adult prevention flow sheets “based upon US Preventive Services Task Force recommendations through March, 2003”

Documenting Prevention in ezSOAP Good to document Chief Complaint: Prevention although other phrases, Well Child, Annual, Well Woman are acceptable Document recommended services covered per check list ROS, PFSH must be recorded PE – Note CMS requirements for details of female exam are in Normal check lists. Naked diagnoses acceptable Must document counseling & follow up!

Documentation of “Separate Identifiable Services” Complete documentation of Preventive history first New Chief Complaint(s) & HPI(s) Physical exam does not have to be separated out! Separate Assessments – must not be “naked” It helps to double-space after Preventive Plan to make it clear what the MDM of the Separate Identifiable Service is.

Practice for next month Make sure you use all the documentation forms provided for each young Medicaid Well Child visit Document others in ezSOAP Reflect on strengths and weaknesses of each approach to documentation Document appropriately separately identifiable services, even if that insurance does not permit billing them.