|
Type of Wellness Exam
|
|
|
Eligibility Date
|
Date of Last Exam
|
|
Date of Last IPPE/AWV
|
|
|
Advance Directive
|
Code Status
|
|
Vital Signs (YES = normal NO = abnormal)
|
Notes and Plan
|
|
Health Risk Assessment Form
|
|
|
Individual and family history reviewed
|
Significant findings/changes
|
|
Chronic problem list/risk factor reviewed
|
Significant findings/changes
|
|
Chronic dx education materials were offered/provided?
|
If yes, describe
|
|
Other providers reviewed
|
Physicians - Specialty - Last Visit
|
|
Home Health
|
Hospice
|
|
Notes and Plan
|
|
|
Allergies reviewed
|
Significant findings/changes
|
|
Medication list reviewed
|
Significant findings/changes
|
|
Hospitalization list reviewed
|
Hospitalizations (date - location - dx)
|
|
Note and Plan
|
|
|
Cognitive Impairment Assessment
|
|
|
General Appearance
• • •
|
Mood/Affect
• • •
|
|
Input from others
|
|
|
GPCOG obtained
|
GPCOG Results
• • •
|
|
Notes and plan
|
|
|
Depression Screening
|
|
|
Expresses interest/pleasure
|
If no, explain
|
|
Felt down depressed/hopeless
|
If yes, explain
|
|
PHQ-9 obtained
|
PHQ-9 Results
• • •
|
|
Notes and Plan
|
Depression resources provided
|
|
Functional Ability
|
|
|
Exhibit a steady gait
|
Time to get up & walk
|
|
Is the patient self reliant?
|
Handle his/her own medications
|
|
Patient handle his/her own money
|
Is the patient’s home safe
|
|
Hearing difficulties
|
Vision difficulties
|
|
Notes and plan
|
|
|
Alcohol Screening (G0442)
|
|
|
Alcohol use?
|
Explain
|
|
AUDIT Screening Provided
|
AUDIT score
• • •
|
|
Notes and Plan
|
|
|
alcohol behavior counseling (15min) G0443
|
alcohol behavior counseling (15-30min) (G0396)
|
|
alcohol behavior counseling (>30min) G0397
|
Time spent on counseling/planning (Refer to codes)
|
|
Smoking and Tobacco Screening
|
|
|
Current Smoker?
|
Pack-year history
|
|
Former smoker
|
Pack-year history
|
|
When did they quit smoking?
|
|
|
Other tobacco products
|
Other tobacco products used
|
|
Notes and Plan
|
Time spent on counseling
|
|
Counseling times
|
|
|
Advance Care Planning
|
|
|
Advance care planning (99497)
|
Notes and plan
|
|
Other Relevant Findings
|
Notes and plan
|
|
BILLING
• • •
|
|
