From Well Baby to Geriatric AssessmentsCreating Value Before You Identify a Problem

Documentation that insurers will pay for

Learning ObjectivesWhat the frame of a Preventive Service visit

includes & excludesWhat insurers want to see documentedContent of GTFC Preventive Service paper

templatesHow to document Preventive Services in

ezSOAPDocumentation of “separate identifiable

services”Practice over next month

Defining Preventive ServicesAge/gender specific history & exam to detect

asymptomatic diseaseCounseling for all recommended screening tests

and immunizations – order/referral if appropriateReview 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”

ExamplesDetection of new problem requiring RxEvaluation of new problem requiring testing (not

included in age/gender preventive services) & follow up

Renewal of Rxes for chronic condition(s) at targetChange 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 orderedROS, PFSH updateAge/gender exam to detect asymptomatic diseaseList of insignificant and trivial diagnoses as well as

chronic at target diagnosesCounseling donePlan 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

evidenceSupplemented by “Denver PDQ” developmental

screens through age 5Must be used for all Missouri Medicaid patients

per ageAdult prevention flow sheets “based upon US

Preventive Services Task Force recommendations through March, 2003”

Documenting Prevention in ezSOAPGood 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 recordedPE – Note CMS requirements for details of

female exam are in Normal check lists.Naked diagnoses acceptableMust document counseling & follow up!

Documentation of “Separate Identifiable Services”Complete documentation of Preventive

history firstNew 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 monthMake sure you use all the documentation

forms provided for each young Medicaid Well Child visit

Document others in ezSOAPReflect on strengths and weaknesses of each

approach to documentation Document appropriately separately

identifiable services, even if that insurance does not permit billing them.