Annual Wellness Exam - HCPIPA

1 Patient Name: DOB: Member ID: DOS. Initial Annual Wellness Exam Annual G0438 G0439. COMPREHENSIVE HEALTH ASSESSMENT. Vital Signs: 2010F T: BP: / P: R: 2001F Wt: lbs Ht: ft in BMI: Allergies: NKA Yes ; if yes, specify: Environmental: None Yes if Yes, specify Specify Medication Reaction 1. 1. 2. 2. 3. 3. 4. 4. Constitutional: WNL, or positive for: HEENT: WNL, or positive for: Cardiac: WNL, or positive for: Chest wall: AICD PPM (If present, state underlying arrhythmia in diagnoses section below). Pulmonary: WNL, or positive for: Decreased breath sounds: No Yes If yes, specify: Prolonged expiration: No Yes Abdominal: WNL, or positive for: Extremities: WNL, or positive for: Vascular: Right Pedal Pulses: Strong Weak Not Palpable Left Pedal Pulses: Strong Weak Not Palpable Carotid Bruit: No Yes If Yes, specify: Left Right Both Ulcer (>8 weeks): No Yes ; If yes, specify location and stage: Musculoskeletal: WNL, or positive for: Joint deformity: No Yes ; If yes, specify: Neuro/Psych: Negative, or positive for: Neuro: CN II-XII intact: Yes No if No, specify Reflexes: equal unequal (specify).

2 Romberg's Test: Neg Pos (specify). Gait: Normal Abn (specify). Motor Strength: RUE: /5 RLE: /5 LUE: /5 LLE: /5. Sensory Loss: No Yes ; If yes, specify: Focal Deficit: No Yes ; If yes, Type/ Location (specify, Rt. Lt or Both): GI: Negative, or positive for: GU: Negative, or positive for: Ostomy: No Yes ; if yes, specify Metabolic/Endo: No Abn Findings Positive for: Specify Diagnoses & Treatment Plan for All Positive Findings Page 1 of 10. Patient Name: DOB: Member ID: DOS. CURRENT MEDICATIONS. Medications (include Rx & OTC meds) Dose & Frequency Prescriber 1. 1. 1. 2. 2. 2. 3. 3. 3. 4. 4. 4. 5. 5. 5. 6. 6. 6. 7. 7. 7. 8. 8. 8. 9. 9. 9. 10. 10. 10. Medication Review & Reconciliation Yes CPT II: 1160F (report additional meds on separate med sheet). Performed by a prescribing practitioner or clinical No Explain: pharmacist and updated medication list incorporated into medical record.

3 Date: Signature: _____MD DO NP PA. (circle one). Use of Anti-Inflammatory or analgesic over-the- Yes CPT II: 1007F. counter (OTC) medications for symptom relief No Explain: assessed Discharge medications reconciled with the Yes CPT II: 1111F Discharge Date: current medication list in medical record (applicable if dischg within the previous 30 days) N/A No Explain: LAB / RADIOLOGY / SCREENING TEST & PREVENTATIVE SERVICES. Mammogram No Explain: Women 50-74 yrs of age Yes CPT II 3014F Results Reviewed DOS: Valid if performed between Oct 1st Results: two years prior to the measurement year through Dec N/A If N/A, specify reason 31st of the measurement year. Colorectal Cancer Screening No Explain: Patients 50-75 yrs of age Yes CPT II 3017F Results Reviewed and Documented Specify Test: Date: Results: Neg Pos (specify). N/A If N/A, specify reason Influenza Vaccine Influenza Adm: Yes CPT II1030F Date: No CPT II G8483 Reason Documented (specify): Pneumococcal Vaccine Pneumococcal Adm: Yes Date: No if No, specify reason: Osteoporosis Screening Dexa-Scan: No Yes CPT II 3095F Results Reviewed Page 2 of 10.

4 Patient Name: DOB: Member ID: DOS. Women 65-85 yrs of age Date: Results: Neg Pos Osteoporosis Fracture Hx: No Yes CPT II 5015F Documented Hx of Fx Fractures of fingers, toes, face &. skull excluded from required Bone Date: Fx Cause: Pathologic Stress Traumatic Density or Rx post-fracture Location: treatment within(6) months after the date of fracture Treatment of Women 65-85 within the six (6) months after the date of Fx Treated: No if No, specify reason Yes if yes, specify Tx: BMD or Rx CPT II 4005F specify Rx Date Prescribed: Reason/Other: Rheumatoid Arthritis Rheumatoid Arthritis: No Yes if yes, specify DMARD. Disease-Modifying Anti-Rheumatic ICD9. Drug Therapy (DMARD) for patients with Rheumatoid Arthritis RA Disease Activity Status: 3470F Low 3471F Moderate 3472F High (ART) DMARD: No if No, specify reason Yes CPT II 4187F specify Rx Blood Pressure Screening and Most Recent B/P: Date: Control Systolic: 3074F < 130 mm/Hg 3075F 130-139 mm/Hg 3077F 140 mm/Hg or >.

5 Patients 60-85 WITHOUT. diagnosis of diabetes Diastolic: 3078F <80 mm/Hg 3079F 80-89 mm/Hg 3080F 90 mm/Hg or >. (Target BP < 150/90) Hx of HTN: No Yes if Yes, specify diagnosis in Diagnosis/Treatment section DIABETES CARE. Blood Pressure Screening and Most Recent B/P: Date: Control Systolic: 3074F < 130 mm/Hg 3075F 130-139 mm/Hg 3077F 140 mm/Hg or >. Patients 60-85 WITH a diagnosis of diabetes Diastolic: 3078F <80 mm/Hg 3079F 80-89 mm/Hg 3080F 90 mm/Hg or >. (Target BP < 140/90) Hx of HTN: No Yes if Yes, specify diagnosis in Diagnosis/Treatment section Hemoglobin A1c (HbA1C) No Yes if Yes, specify: Date: Value: Diabetic Blood Sugar Control (target HbA1C < 9%): Results: 3044F < 7% 3045F 3046F Greater than 9%. Glomerular Filtration Rate (GFR) No Yes if Yes, specify: Date: Value: GFR Results: than 90 60-89 30-59. 15-29 <15. Microalbuminuria No Yes if Yes, specify: Date: Value: If no other indication of renal Dz CPT II: 3061F Neg Microalbuminuria 3060F Positive Microalbuminuria Eye Exam No Yes if yes, specify: Date: Practitioner Document review of eye exam report w/interpretation by an Results Exam: Ophthalmologist or Optometrist FUNCTIONAL/PSYCHOSOCIAL STATUS.

6 Hospital Discharge Patient discharged from an Within the last 60 days Yes CPT II: 1110F No (none). inpatient facility ( , acute hospital, SNF, or rehab) Within the last 6 months Yes No (none). Page 3 of 10. Patient Name: DOB: Member ID: DOS. Cognition Status Cognition assessed and reviewed: Yes CPT II: 1494F No Score Mini-Cog Tool Score (specify other tool used) 3 Recalled Words - Neg cog impair 1-2 Recalled Words + Normal CDT-Neg cog impair 1-2 Recalled Words + Abn CDT - Pos cog impair 0 Recalled Words - Pos for cog impair Cog Impairment: No Yes If Yes, specify ICD9: Notes: Functional Status Functional Status Assessed: Yes CPT II: 1170F No if No, explain Assessment Performed Ambulatory Status Assessment: Inclusive of: No deficit Difficulty Walking Abnormality of Gait Ambulatory status, Sensory ability [hearing; Other ICD9: Devices Used: vision; speech] Notes: Functional independence ( Sensory Functional Status: ADLs inclusive of bathing, dressing, eating, etc.)

7 Hearing: No Deficit Hearing Loss ICD9: Deaf ICD9: Devices Used: Functional Indep Score: Vision: No Deficit Visual Loss ICD9: Blind ICD9: 0 Functional Independent Devices Used: 1 Requires supervision, Speech: No Deficit Deficit ICD9: encouragement or cueing Notes: 2 Requires limited assistance Functional Independence: 3 Requires extensive assistance Locomotion Score: 0 1 2 3 Note: Dressing Score: 0 1 2 3 Note: (Circle applicable score for each). Eating Score: 0 1 2 3 Note: Meal Prep Score: 0 1 2 3 Note: Toileting Score: 0 1 2 3 Note: Bathing Score: 0 1 2 3 Note: Transferring Score: 0 1 2 3 Note: Shopping Score: 0 1 2 3 Note: Driving Score: 0 1 2 3 Note: Using the Phone Score: 0 1 2 3 Note: Laundry Score: 0 1 2 3 Note: Housework Score: 0 1 2 3 Note: Taking Meds Score: 0 1 2 3 Note: Date: Depression Screening Yes CPT II: 3725F Screening Tool (if other than PHQ-9): Standardized depression screening/assessment tool Score: 0 Neg for Depression 1-4 Minimal Depression 5-9 Mild Depression 10-14 Moderate Depression 15-19 Moderately Severe Depression PHQ-9 (specify other tool used).

8 20-27 Severe Depression ICD9: Plan: Not Screened Explain: Date Page 4 of 10. Patient Name: DOB: Member ID: DOS. Home Environment Lives Alone Lives with Family Caretaker (specify). Notes: Pain Screening Yes CPT II: 1126F No Pain Present 1125F Pain Present (level 1 no care plan required). Performed (with, as appropriate, a comprehensive pain management 0521F Care Plan addressing Pain level of 2 or >. plan) Pain Scale: O No Pain 1 Mild Pain 2 Mod Pain 3 Severe Pain 4 Extreme Pain 5 Pain as bad as it could be Plan (include origin of pain): Not Screened If Not, explain: Date Advance Care Planning Yes CPT II: 1158F Advance Directive discussed & document Discussed (as evidenced by the presence of an Advanced Care Plan in the medical 1157F Advanced Directive on file 1124F Discussed but Pt refused Advance Directive record or documentation of an Advance Care Planning discussion) No If No, explain: Date Fall Risk Management Yes CPT II: 1101F Fall Risk Asses (0-1 falls in the past yr).

9 Discussed fall prevention (documented discussion present in 1100F Fall Risk Asses (2 or more fall in past yr) 3288F Fall Risk Assessment (documented). the medical record) Plan: Not Discussed Explain: Date Management of Urinary Presence or absence of Incontinence Assessed CPT II: 1090F. Incontinence in Older Adults Discussion and assessment of Yes CPT II: Denies UA Incontinence 1091F UA Incontinence Present urinary incontinence (documented 0509F UA Incontinence Plan of Care Documented discussion present in the medical record) Plan: Not Accessed Explain: Date Physical Activity Counseling Yes CPT II: 1003F Level of Activity Assessed Patient counseled about their level of exercise or physical activity and 4019F Exercise & VitD/Calcium use discussed 3115F Quantative Eval of Current Level of Act use of Vitamin D and/or Calcium (if Plan: applicable). Not Assessed CPT II: 3119F Explain: Date Substance Use History Tobacco Use Assessment: CPT II: 1000F.

10 Current Smoker: No (non-smoker) Yes per day use: Prior Hx of Tobacco use: No Yes per day use: Last Smoked: Alcohol and/or Substance Abuse Assessment: HCPCS: G0396. Alcohol Abuse: Yes Specify ICD9: No (none - moderate alcohol use). Substance Abusebuse: Yes Specify ICD9: No (none drug dependent). Plan: Date Page 5 of 10. Patient Name: DOB: Member ID: DOS. DIAGNOSES & TREATMENT PLAN. Status: N=New S=Stable I=Improved W= Worsening NERVOUS SYSTEM. CVA/Stroke ICD-9: Status: N S I W. Plan: Parkinson's/Huntington's Disease ICD-9: Status: N S I W. Plan: Peripheral Autonomic Neuropathy ICD-9: Status: N S I W. Plan: Peripheral Neuropathy ICD-9: Status: N S I W. Plan: Hemiplegia/Hemiparesis ICD-9: Status: N S I W. Plan: Quadriplegia/Paraplegia ICD-9: Status: N S I W. Plan: Seizures/Epilepsy ICD-9: Status: N S I W. Plan: PULMONARY. COPD ICD-9: Status: N S I W. Plan: Chronic Bronchitis / Obstructive ICD-9: Status: N S I W.