FAST GUIDE TO PAY FOR PERFORMANCE FOR MEDI-CAL MEMBERS * Incentive Body Mass Index (BMI) Annual (once per calendar year) $25 Women’s Health Exam - $90 or Child (3-6 yrs) Teen (12-18 yrs) Well Visit - $90 Diabetes $30 for tests $65 for results Depression Screening $30 Post-discharge Visit Per Occurrence $90 Adult (age 21+) For diabetic patient: Order and ensure completion of annual tests: HbA1C (and test results < 8%) LDL-C ( and test results <100 mg/dL) Retinal eye screening Nephropathy screening Measure BMI and give nutrition/exercise counseling, referral or health education Document in the medical record Bill – code 99411, modifier WT, and BMI Dx [see reverse side for BMI diagnosis code] For Children 3-6 or Teens 12-18 years old: Perform an annual well visit Complete the SHA tool and keep in the medical record Bill – see reverse side or Coding Tip Sheet for Child/Teen Well Visit For diabetic patient: Order and ensure completion of annual tests: HbA1C (and test results < % for age) LDL-C ( and test results < 100 mg/dL) Retinal eye screening Nephropathy screening For Members 18+ years old: Conduct a screening for depression using HPSM’s consolidated screener or any standard depression screening tool. Save a copy of the completed screener in the medical record Bill – G8510 for negative screen, or G8431 for positive screen and follow-up plan documented. For Members 18+ years old: Conduct a screening for depression using HPSM’s consolidated screener or any standard depression screening tool. Save a copy of the completed screener in the medical record Bill – G8510 for negative screen, or G8431 for positive screen and follow-up plan documented. Measure, height, weight and BMI Document in the medical record Bill – code 99411, modifier WT, and BMI Dx [see reverse side for BMI diagnosis code] For Women 20-64 years old: Perform cervical (pap smear) or vaginal cancer screening, pelvic and clinical breast exam Bill – procedure code (HCPCS) G0101 See member within 14 days of hospital discharge: Review the hospital discharge summary Conduct a clinical assessment, and Reconcile medications & document in the medical record Bill for the type and scope of visit (e.g. 99201-99205, 99211-99215) Initial Health Assessment (IHA) and Staying Healthy Assessment (SHA) form - $90 For new member: (within 120 days of HPSM enrollment) Perform IHA Complete the SHA keep in medical record Bill– see reverse side or Coding Tip Sheet for Initial Health Assessment Visit Pregnancy PCP: For a pregnant woman in her first trimester PCP Ref - $50 OB Visit - $100 Postpartum $50 Child/Teen Refer patient to OB provider Help make an appointment with OB Complete HPSM OB referral form Fax form to (650) 829-2009 For new member: (within 120 days of HPSM enrollment) Perform IHA Complete the SHA and keep in medical record Bill– see reverse side or Coding Tip Sheet for Initial Health Assessment Visit OB: See HPSM pregnant woman in 1st trimester Complete HPSM OB Visit form Fax form to (650) 829-2009 Perform postpartum exam 21-56 days after delivery Bill – CPT code 59430 & modifier PP, and indicate delivery date in remarks section of the claim *Please see HPSM’s Pay for Performance Program binder for complete guidelines or find them online at www.hpsm.org/providers/medi-cal-p4p.aspx 2014 Incentive Body Mass Index (BMI) Postpartum Exam Depression Screening Women’s Health Exam Child Well Visit Teen Well Visit Initial Health Assessment (IHA) CPT Code Modifier Description 99411 WT Incentive payment for measuring and recording BMI Pay $25 59430 PP OB/GYN: Postpartum exam completed within 21-56 days post delivery $50 G8510 ― Negative screen result $30 G8431 ― Positive screen result and follow-up plan documented $30 G0101 ― Cervical (Pap smear) / vaginal cancer screening, pelvic & clinical breast exam $90 99392 ― Established Patient, Child (Age 3 - 4 years) – Well Visit $90 99393 ― Established Patient, Child (Age 5 - 6 years) –Well Visit $90 99394 ― Established Patient, Adolescent, (Age 12 - 17 years) – Well Visit $90 99395 ― Established Patient, use for 18 year olds – Well Visit $90 1st 99381 ― Initial Comprehensive Preventive Visit (Under 1 year of age) – 99382 ― New Patient, Early Childhood (Age 1 - 4 years) – Well Baby Visit Well Baby Visit $90 $90 $90 99383 ― New Patient, Late Childhood (Age 5 - 11 years) – Well Child Visit 99384 ― New Patient, Adolescent (Age 12 - 17 years) – Well Adolescent Visit $90 99385 ― New Patient, Adult (Age 18 - 39) – Well Adult Visit $90 99386 ― New Patient, Adult (Age 40 - 64) – Well Adult Visit $90 99387 ― New Patient, Adult (Age 65+) – Well Adult Visit $90 Body Mass Index (BMI) diagnosis codes: ADULT Body Mass Index (BMI) BMI adult codes are for use for persons over 20 years old and some require 5 digit specificity. BMI ICD-9 Code ICD-10 Code < 19 V85.0 Z68.1 19.0-19.9 V85.1 Z68.1 20.0-20.9 V85.1 Z68.20 21.0-21.9 V85.1 Z68.21 22.0-22.9 V85.1 Z68.22 23.0-23.9 V85.1 Z68.23 24.0-24.9 V85.1 Z68.24 25.0-25.9 V85.21 Z68.25 26.0-26.9 V85.22 Z68.26 27.0-27.9 V85.23 Z68.27 PEDIATRIC Body Mass Index (BMI) Note: BMI pediatric codes are for persons 2-20 years old. These percentiles are based on the growth charts published by the Centers for Disease Control and Prevention (CDC) ICD-9 codes require 5 digit specificity. BMI Percentile ICD-9 Code ICD-10 Code < 5th % for age V85.51 Z68.51 5% to < 85% for age V85.52 Z68.52 85% to < 95% for age V85.53 Z68.53 ≥ 95% for age V85.54 Z68.54 Nutrition Counseling V65.3 Z71.3 Physical activity Counseling V65.41 none Diagnosis Codes to use with IHA, Child & Teen Well Visits: ICD-9 Code 28.0-28.9 V85.24 Z68.28 29.0-29.9 V85.25 Z68.29 30.0-30.9 V85.30 Z68.30 31.0-31.9 V85.31 Z68.31 32.0-32.9 V85.32 Z68.32 33.0-33.9 V85.33 Z68.33 34.0-34.9 V85.34 Z68.34 35.0-35.9 V85.35 Z68.35 36.0-36.9 V85.36 Z68.36 37.0-37.9 V85.37 Z68.37 38.0-38.9 V85.38 Z68.38 39.0-39.9 V85.39 Z68.39 40.0-44.9 V85.41 Z68.41 V70.6 45.0-49.9 V85.42 Z68.42 V70.8 50.0-59.9 V85.43 Z68.43 V70.9 60.0-69.9 V85.44 Z68.44 70+ V85.45 Z68.45 V20.2 V70.0 V70.3 V70.5 Definition Routine child check (over 28 days old) Developmental testing of infant or child Immunizations appropriate for age Routine vision and hearing testing Routine general medical examination at a health care facility General medical examination for: o Driver’s license o Camp o Immigration and o Adoption naturalization o School admission o Sports competition o Insurance certification Occupational health examinations Pre-employment screening Armed forces personnel Health examination of defined subpopulations o Students o Preschool children o School children o Inhabitants of institutions Health examination in population surveys Other specified general medical examinations Examination of potential donor of organ or tissue Unspecified general medical examination OVER
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