Primary Care Physician Health Risk...
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PATIENT FIRST NAME PATIENT LAST NAME DATE OF SERVICE (MM/DD/YYYY) PATIENT DATE OF BIRTH (MM/DD/YYYY) PATIENT GENDER AMERIGROUP MBR ID PHYSICIAN PHONE NUMBER PHYSICIAN FAX NUMBER PROVIDER ID NUMBER PROVIDER ID TYPE PHYSICIAN LAST NAME PHYSICIAN FIRST NAME SECTION 2 - HEALTH MAINTENANCE ACTIVITIES DATE OF LAST OFFICE VISIT W/ PCP (MM/DD/YYYY) INFLUENZA VACCINATION IN THE LAST 12 MONTHS? PNEUMONIA VACCINATION IN THE LAST 5 YEARS? HERPES ZOSTER (SHINGLES) VACCINATION? IF YES, OSTEO SCREENING DATE (MM/DD/YYYY) OSTEOPOROSIS SCREENING SECTION 1 - PHYSICAL EXAM BLOOD PRESSURE UPRIGHT (SYS/DYS) WEIGHT (POUNDS ONLY) HEIGHT (INCHES ONLY) BMI SECTION 3 - SCREENING TESTS - Select services rendered accordingly, service date and corresponding results. Services must have been rendered in the current calendar year or prior year as identified below: Primary Care Physician Health Risk Assessment Instructions: The Primary Care Physician Health Risk Assessment must be completed by an MD, NP or PA in a face-to-face visit on the date of service documented. To receive compensation for HRA completion, a CMS-acceptable physician's signature and credentials must be documented in the signature line. Please Note: Physician's signature should be the final step in completing the form because it locks the entire form and no further edits can be made. Additionally, please print characters in CAPITAL letters; consider using your CAPS lock key. For additional instructions, refer to our provider self-service site or your Provider Relations representative. RESULTS RESULTS SCREENING DATE (MM/DD/YYYY) RESULTS SCREENING DATE (MM/DD/YYYY) SCREENING DATE (MM/DD/YYYY) RESULTS 3 A. DIABETES MANAGEMENT HBA1C? MACROALBUMIN MICROALBUMIN START DATE (MM/DD/YYYY) LDL RETINAL EYE EXAM BY OPTOMETRIST OR OPHTHALMOLOGIST? RESULTS EXAM DATE (MM/DD/YYYY) CURRENTLY TAKING AN ACE INHIBITOR OR ARB? SCREENING DATE (MM/DD/YYYY) 3 B. PREVENTIVE CARE IF YES, SCREENING TYPE? COLON CANCER SCREENING? RESULTS SCREENING DATE (MM/DD/YYYY) GLAUCOMA SCREENING? RESULTS YEAR PERFORMED (YYYY) MAMMOGRAPHY? SCREENING DATE (MM/DD/YYYY) HRA Return Fax Number: 1-888-762-3219 HRA COMPLETED WITH TODAY'S FACE-TO-FACE ENCOUNTER
Transcript of Primary Care Physician Health Risk...
PATIENT FIRST NAMEPATIENT LAST NAME
DATE OF SERVICE (MM/DD/YYYY)
PATIENT DATE OF BIRTH (MM/DD/YYYY)
PATIENT GENDER
AMERIGROUP MBR ID
PHYSICIAN PHONE NUMBER PHYSICIAN FAX NUMBER
PROVIDER ID NUMBER
PROVIDER ID TYPE
PHYSICIAN LAST NAME PHYSICIAN FIRST NAME
SECTION 2 - HEALTH MAINTENANCE ACTIVITIESDATE OF LAST OFFICE VISIT W/ PCP (MM/DD/YYYY)
INFLUENZA VACCINATION IN THE LAST 12 MONTHS?
PNEUMONIA VACCINATION IN THE LAST 5 YEARS?
HERPES ZOSTER (SHINGLES) VACCINATION?
IF YES, OSTEO SCREENING DATE (MM/DD/YYYY)
OSTEOPOROSIS SCREENING
SECTION 1 - PHYSICAL EXAM
BLOOD PRESSURE UPRIGHT (SYS/DYS)
WEIGHT (POUNDS ONLY)
HEIGHT (INCHES ONLY) BMI
SECTION 3 - SCREENING TESTS - Select services rendered accordingly, service date and corresponding results. Services must have been rendered in the current calendar year or prior year as identified below:
Primary Care Physician Health Risk Assessment
Instructions: The Primary Care Physician Health Risk Assessment must be completed by an MD, NP or PA in a face-to-face visit on the date of service documented. To receive compensation for HRA completion, a CMS-acceptable physician's signature and credentials must be documented in the signature line. Please Note: Physician's signature should be the final step in completing the form because it locks the entire form and no further edits can be made. Additionally, please print characters in CAPITAL letters; consider using your CAPS lock key. For additional instructions, refer to our provider self-service site or your Provider Relations representative.
RESULTS
RESULTS
SCREENING DATE (MM/DD/YYYY)
RESULTS
SCREENING DATE (MM/DD/YYYY)
SCREENING DATE (MM/DD/YYYY)
RESULTS
3 A. DIABETES MANAGEMENT
HBA1C?
MACROALBUMIN
MICROALBUMIN
START DATE (MM/DD/YYYY)LDL
RETINAL EYE EXAM BY OPTOMETRIST OR OPHTHALMOLOGIST?
RESULTS
EXAM DATE (MM/DD/YYYY)
CURRENTLY TAKING AN ACE INHIBITOR OR ARB?
SCREENING DATE (MM/DD/YYYY)
3 B. PREVENTIVE CARE
IF YES, SCREENING TYPE?
COLON CANCER SCREENING?
RESULTSSCREENING DATE (MM/DD/YYYY)
GLAUCOMA SCREENING?
RESULTSYEAR PERFORMED (YYYY)
MAMMOGRAPHY?
SCREENING DATE (MM/DD/YYYY)
HRA Return Fax Number: 1-888-762-3219
HRA COMPLETED WITH TODAY'S FACE-TO-FACE ENCOUNTER
3 C. CHOLESTEROL MANAGEMENT (In Cardiovascular Conditions)
ISCHEMIC VASCULAR DISEASE
SCREENING DATE (MM/DD/YYYY)
LAB VALUE
LAB VALUE
TOTAL CHOLESTEROL
SCREENING DATE (MM/DD/YYYY)
TRIGLYCERIDES LAB VALUE
SCREENING DATE (MM/DD/YYYY)
LDL LAB VALUE
SCREENING DATE (MM/DD/YYYY)
3 D. ADVANCE CARE PLANNING:
MEMBER HAS ADVANCE DIRECTIVEHAVE YOU DISCUSSED ADVANCE CARE PLANNING WITH THE MEMBER? (E.G., ADVANCE DIRECTIVE, HEALTH CARE PROXY, LIVING WILL, SURROGATE DECISION MAKER)
IF YES, PLEASE PROVIDE DATE: (MM/DD/YYYY)
MEMBER HAS HEALTH CARE PROXY
3 E. COGNITIVE ASSESSMENT
IS MEMBER ABLE TO:
IS MEMBER ORIENTED:
TO DATE? TO TIME? TO DAY OF WEEK?
TO CURRENT LOCATION?
RECALL WORDS?
FOLLOW COMMANDS?
CONCENTRATE WITH NO ATTENTION DEFICITS?
AMBULATE WITHOUT DIFFICULTY?
WALK INDEPENDENTLY ON LEVEL GROUND?
IS MEMBER ABLE TO:
3 F. AMBULATION ASSESSMENT
IS MEMBER ABLE WITHOUT ASSISTANCE TO:
DRESS ? PREPARE MEALS?
COMPLETE HOUSEKEEPING?
COMPLETE SHOPPING?
HAS MEMBER FALLEN IN LAST SIX (6) MONTHS?
IS MEMBER USING DEVICE (CANE, WALKER, ETC.) TO MOVE AROUND HOME?
IF YES, HAVE YOU DISCUSSED URINARY INCONTINENCE WITH MEMBER?
DOES MEMBER HAVE URINARY INCONTINENCE?
3 G. FUNCTIONAL STATUS
3 H. PAIN ASSESSMENT
HAS MEMBER REPORTED EVER EXPERIENCING PAIN?
HAS MEMBER'S PAIN AFFECTED FUNCTION/QUALITY OF LIFE? (E.G., ACTIVITY LEVEL, MOOD, RELATIONSHIPS, SLEEP OR WORK)
AT ITS WORST, HOW SEVERE IS MEMBER'S PAIN? (1 TO 10, WITH 10 BEING THE WORST) PLEASE CHOOSE ONE.
HAVE YOU DISCUSSED PAIN MANAGEMENT OR SUPPORT WITH MEMBER?
CURRENT SMOKER?
IF YES,DIAGNOSIS DATE (MM/DD/YYYY)
DOES MEMBER HAVE COPD?
IF YES, HAS MEMBER HAD SPIROMETRY TESTING?
IF YES, DATE OF SPIROMETRY TESTING (MM/DD/YYYY)
WAS COUNSELING PERFORMED?
IF YES, DATE OF COUNSELING (MM/DD/YYYY)
3 B. PREVENTIVE CARE cont'd
3 I. MEDICATION REVIEW
MEDICATIONS REVIEWED? IF YES, ATTACH MEDICATION LIST.
PLEASE RECORD ALL ACTIVE DIAGNOSES FOR THE CURRENT CALENDAR YEAR THAT SUPPORT ACTIVE MANAGEMENT & TREATMENT
COMMON SYMPTOMS & ACUTE CONDITIONS
ABDOMINAL PAIN 789.00
ABNORMAL WEIGHT LOSS 783.21
ALLERGIC REACTION 995.3
APNEA 786.03
B-12 DEFICIENT 266.2
BLOOD IN STOOL 578.1
CELLULITIS, ABSCESS 682.9
CONFUSION 298.9
CONTUSION 924.9
CONTUSION (EYE) 921.9
CONSTIPATION 564.00
COUGH 786.2
DEHYDRATION 276.51
DIARRHEA 787.91
DIZZINESS 780.4
EDEMA 782.3
FATIGUE 780.79
FEVER 780.60
HEADACHE 784.0
INGROWN TOENAIL 703.0
LOW BACK PAIN/LUMBAGO 724.2
MENTAL STATUS CHANGE 780.97
MUSCLE PAIN 729.1
NAUSEA 787.02
NECK PAIN 723.1
OTITIS MEDIA 382.9
PAIN IN LIMB 729.5
PLEURISY 511.9
SHORTNESS OF BREATH 786.05
SLEEP DISORDER 780.59
SINUSITIS (ACUTE) 461.9
SYNCOPE 780.2
URINARY TRACT INFECTION 599.0
VERTIGO 780.4
VOMITING 787.03
WEIGHT GAIN 783.1
WEIGHT LOSS 783.21
SICKLE CELL TRAIT 282.5
SICKLE CELL ANEMIA 282.60
APLASTIC ANEMIA 284.9
HEMOLYTIC ANEMIA 283.9
PERNICIOUS ANEMIA 281.0
HEMATOLOGIC
ENDOCRINE & METABOLIC DISORDERS cont'd
GANGRENE 785.4
DM/ PERIPHERAL CIRCULATORY DISORDERS 250.7__ (Please specify 5th digit - from drop-down menu)
NEUROGENIC ARTHROPATHY 713.5
POLYNEUROPATHY IN DIABETES 357.2
PERIPHERAL AUTONOMIC NEUROPATHY 337.9
DM W/ NEUROLOGICAL MANIFESTATIONS 250.6__ (Please specify 5th digit - from drop-down menu)
DIABETIC CATARACT 366.41
RETINAL EDEMA 362.83
PROLIFERATIVE DIABETIC RETINOPATHY 362.02
BACKGROUND DIABETIC RETINOPATHY 362.01
DM W/ OPHTHALMIC MANIFESTATIONS 250.5__ (Please specify 5th digit - from drop-down menu)
RENAL DIALYSIS STATUS V45.11
CKD, UNSPECIFIED 585.9
END-STAGE KIDNEY DISEASE 585.6
CKD, STAGE V 585.5
CKD, STAGE IV (SEVERE) 585.4
CKD, STAGE III (MODERATE) 585.3
CKD, STAGE II (MILD) 585.2
CHRONIC KIDNEY DISEASE (CKD), STAGE 1 585.1
NEPHRITIS IN OTHER DISEASES 583.81
NEPHROTIC SYNDR IN OTHER DIS 581.81
DM W/ RENAL MANIFESATIONS 250.4__ (Please specify 5th digit - from drop-down menu)
PERIPHERAL ANGIOPATHY IN OTHER DISEASES 443.89
DM W/ OTHER SPECIFIED MANIFESTATIONS 250.8__ (Please specify 5th digit - from drop-down menu)
LONG-TERM INSULIN USE V58.67
DM W/ HYPEROSMOLARITY 250.2__ (Please specify 5th digit - from drop-down menu)
CIRCULATORY SYSTEM
ATRIAL TACHYCARDIA 427.89
SUPRAVENTRICULAR TACHYCARDIA 427.0
ATRIAL FIBRILLATION 427.31
A-V BLOCK COMPLETE 426.10
PRINZMETAL ANGINA 413.1
ANGINA PECTORIS NEC/NOS 413.9
POST MI SYNDROME 411.0
INTERMED CORONARY SYND 411.1
CAD 414.00
ANGINA DECUBITUS 413.0
AMI, OTHER SPECIFIED SITE 410.80
AMI, UNSPECIFIED 410.90
OLD MYOCARDIAL INFARCTION 412
HEART FAILURE, NOS 428.9
MYOCARDITIS, NOS 429.0
RHEUMATIC HEART FAILURE 398.91
HYPERTENSION, UNSPECIFIED 401.9
HYPERTENSIVE HEART DISEASE 402.90
ENDOCARDITIS 424.90
ATHEROSCLEROSIS 440.9
CARDIOMYOPATHY 425.4
ABNORMAL HEART SOUNDS 785.3
CHEST PAIN, UNSPECIFIED 786.50
ENDOCRINE & METABOLIC DISORDERS
DM, W/O COMPLICATIONS 250.0__ (Please specify 5th digit - from drop-down menu)
DM, W/ KETOACIDOSIS 250.1__ (Please specify 5th digit - from drop-down menu)
ULCERATIVE COLITIS, UNSPEC 556.9
IRRITABLE BOWEL SYNDROME 564.1
IMPACTION INTESTINE NOS 560.30
UNSPECIFIED ESOPHAGITIS 530.10
GERD 530.81
GASTRITIS 535.50
DIVERTICULITIS 562.11
CROHN'S DISEASE NOS 555.9
PANCREATIC DISORDER NOS 251.9
ULCER, PEPTIC W/ PERF & HEMORR 533.60
ULCER, DUODENAL 532.90
ULCER, PEPTIC 533.90
ULCER, DUODENAL W/ PERF & HEMORR 532.60
ULCER, GASTRIC 531.90
ULCER, GASTRIC W/ PERF & HEMORR 531.60
DIGESTIVE SYSTEM
ASTHMA, UNSPECIFIED 493.00
CHRONIC AIRWAY OB NEC 496
PULMONARY EDEMA 514
UPPER RESPIRATORY INFECTION 465.9
INFLUENZA 487
COMMON COLD 460
STAPH PNEUMONIA UNSPECIFIED 482.40
PNEUMONIA, VIRAL 480.9
PNEUMONIA, BACTERIAL UNSPECIFIED 482.9
CYSTIC FIBROSIS NEC 277.09
CYSTIC FIBROSIS W/O ILEUS 277.00
CHRONIC BRONCHITIS NOS 491.9
ACUTE BRONCHITIS 466.0
CHRONIC OB ASTHMA NOS 493.20
EMPHYSEMA NEC 492.8
RESPIRATORY SYSTEM
LUPUS 710.0
DJD, UNSPECIFIED 715.90
ARTHRALGIA 719.40
RHEUMATOID ARTHRITIS 714.0
OSTEOARTHROPATHY, LOCALIZED 715.30
OSTEOARTHRITIS, UNSPECIFIED 715.90
ARTHRITIS, UNSPECIFIED 716.90
RADICULOPATHY 729.2
SCIATICA 724.3
DISORDER OF THE BONE, UNSPEC 733.90
PATHOLOGIC VERTEBRAE FRACTURE 733.13
PATHOLOGIC HIP FRACTURE 733.14
SKELETAL
HERPES, SIMPLEX 054.9
ASYMP HIV INFECTN STATUS V08
HIV-2 INFECTION OTH DIS 07953
HUMAN IMMUNO VIRUS DIS 042
LIVER CANCER 155.2
PROSTATE CANCER 185
LYMPH NODE CANCER 196.9
LUNG CANCER 162.9
BREAST CANCER, FEMALE PRIMARY 174.9
HERPES, ZOSTER 053.10
BONE CANCER, UNSPECIFIED 170.9
CANCER & INFECTIOUS DISEASE
CEREBRAL PALSY NOS 343.9
MULTIPLE SCLEROSIS 340
SPINAL CORD INJURY NOS 952.9
SPINAL CORD DISEASE NOS 336.9
PARALYSIS NOS 344.9
MONOPLEGIA NOS 344.5
MIGRAINE, UNSPECIFIED 346.90
QUADRIPLEGIA 344.00
DISORDER OF NERVOUS SYSTEM NOS 349.9
PARAPLEGIA NOS 344.1
DIPLEGIA OF UPPER LIMBS 344.2
EPILEPSY, UNSPECIFIED 345.90
PARKINSON'S 332.0
MUSCULAR DYSTROPHY 359.1
CONVULSIONS 780.39
ALZHEIMER'S 331.0
NERVOUS SYSTEM
LATE EFFECT OF SELF-INJURY E959
ANXIETY GENERALIZED 300.02
SELF-INJURY, NOS E9589
DEMENTIA 294.8
SCHIZOPHRENIA NOS-REMISS 295.95
SIMPLE SCHIZOPRENIA, UNSPEC 295.00
ACUTE ALCOHOL INTOX, UNSPEC 303.00
PARANOID STATE NOS 297.9
DEPRESSIVE DISORDER 311
ALCOHOLISM IN REMISSION 303.93
DRUG DEPENDENCE, NEC, UNSPECIFIED 304.60
CHRONIC ALCOHOL DEPENDENCE 303.90
MAJOR DEPRESSION, SINGLE EP 296.20
EPISODIC MOOD DISORDER 296.90
BIPOLAR DISORDER NEC 296.89
MENTAL HEALTH
SPASTIC HEMIPLEGIA 342.10
ANEURYSM NOS 442.9
ATHEROEMBOLISM 445.89
ART OCC NOS W/ INFARCTION 434.91
OCCLUSION ART NOS, W/ INFARCTION 433.91
HISTORY OF CVA V12.54
INTRACRANIAL HEMORAGE NOS 432.9
FLACCID HEMIPLEGIA 342.00
CEREBROVASCULAR DISEASE 436 (ACUTE, BUT ILL-DEFINED)
PERIPH VASCULAR DISORDER NOS 443.9
VASCULAR & CEREBROVASCULAR
DERMATOSIS 709.9
PRESSURE ULCER 707.00
CHRONIC SKIN ULCER 707.9
SKIN
CREDENTIALSPHYSICIAN'S SIGNATURE
OTHER (WRITE IN)
