Responses to Plaintiffs' Request for Production of Documents Set One
Public Court Documents
March 19, 1991
328 pages
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Case Files, Matthews v. Kizer Hardbacks. Responses to Plaintiffs' Request for Production of Documents Set One, 1991. 8457b479-5c40-f011-b4cb-0022482c18b0. LDF Archives, Thurgood Marshall Institute. https://ldfrecollection.org/archives/archives-search/archives-item/268f5d47-e1ce-49ec-9e83-c696d8cd8e72/responses-to-plaintiffs-request-for-production-of-documents-set-one. Accessed June 17, 2025.
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COURT PAPER
27
STATE OF CALIFORNIA
STD. 113 (REV. 8:72)
85 34769
% NECENVE
a 1) pent OJ. rede N
HH
DANIEL E. LUNGREN, Attorney General
of the State of California SIRS INE
HARLAN E. VAN WYE, Deputy Attorney General NAACP LEGAL DEFENSE AND
455 Golden Gate Avenue, Suite 6200 EQUCATIONAL FURD, INC,
San Francisco, CA 94102
Telephone: (415) 464-1173
Attorneys for Respondents and Defendants
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA
ERIKA MATTHEWS; et al., CIV. NO. C-90-3620 EFL
Plaintiff, CLASS ACTION
vs. RESPONSES TO PLAINTIFFS'
REQUEST FOR PRODUCTION
KENNETH KIZER, OF DOCUMENTS
Defendant. [SET ONE]
REQUEST NO. .):
All documents that refer or relate to the Department's
policies and/or procedures, including such policies and/or
procedures, regarding the EPSDT/CHDP Programs coverage of lead
blood level assessments.
RESPONSE TO REQUEST NO. 1:
All documents that refer or relate to the Department's
policies and/or procedures, including such policies and/or
procedures, regarding the EPSDT/CHDP Programs coverage of lead
blood level assessments are marked as Exhibits 1, 2, 3, 4,5,
and 6.
-1A- A
a
COURT PAPER
27
STATE OF CALIFORNIA
STD. 113 (REV. 8.72)
85 34769
REQUEST NO. 2:
All manuals, letters, operating instruction letters,
bulletins or other documents promulgated after January 1, 1985,
that refer or relate to instructions to providers or lead blood.
RESPONSE TO REQUEST NO. 2:
All manuals, letters, operating instruction letters,
bulletins or other documents promulgated after January 1, 1985,
that refer or relate to instructions to providers or lead blood
are marked as Exhibits 7, 8, 9, 10 and 11.
DATED:
Respectfully submitted,
DANIEL E. LUNGREN, Attorney General
of the State of California
STEPHANIE WALD,
Supervising Deputy Attorney General
HARIAN E. VAN WYE,
Deputy Attorney General
By
HARIAN E. VAN WYE
Attorneys for Defendant
COURT PAPER
STATE OF CALIFORNIA
STD. 113 (REV. 8-72)
85 34769
VERIFICATION
I, GORDON CUMMING, hereby declare:
I am a Health Program Manager and the Branch Chief for the
Child Health and Disability Prevention Branch in the Family
Health Division, Department of Health Services, State of
California. As such, I am authorized to make this verification
on behalf of the State of California.
I have read the foregoing Responses to Plaintiffs' Request
For Production of Documents and know the contents thereof. The
sald responses were prepared with the assistance and advice of
counsel and employees of said Department upon whose advice and
information I have relied. The responses set forth herein,
subject to inadvertent or undiscovered errors, are based on and,
therefore, necessarily limited by the records and information
still in existence, presently recollected and thus far
discovered in the course of the preparation of these responses.
I, and the State Department of Health Services, consequently
reserve the right to make any changes in the responses if it
appears at any time that omissions or errors have been made
therein or that more accurate information is available. Subject
to the limitations set forth herein the said responses are true
to the best of my knowledge, information or belief.
LAL
/. [oA
flit
ball on
COURT PAPER
27
STATE OF CALIFORNIA
STD. 113 (REV. 8-72)
85 34769
I declare under penalty of perjury under the laws of the
State of California that the foregoing is true and correct.
Executed on JH) J /99) , at Sacramento,
/
California.
ado? a
ORDON CUMMING, gHief
Child Health and Disability
Branch
STATE OF CALIFORNIA—HEALTH AND WELFARE AGENCY GEORGE DEUKMEJIAN, Governor
DEPARTMENT OF HEALTH SERVICES
714/744 P STREET
SACRAMENTO, CA 95814
Arthur D. Lisbin, M.D.
County of Los Angeles
Department of Health Services
313 North Figueroa Street
Los i CA 90012
tter commenting on the current medical guidelines which require a Free
Erythrocyte Protoporphyrin (FEP) Test before doing a Blood Lead Level Determina-
tion has been received.
These guidelines are currently under revision. You will note, however, that the
requirement was dropped from the new PM 160 Instructions (page 8).
Dr. Lynn Goldman, Chief of the State Enviromental Epidemiology and Toxicology
Section, states that if a single test is desired the.preferred test should be a
Blood Lead. Ideally, however, one should obtain: cbnecurrent measures of both
since FEP reflects past exposure better than Pb B Jespecially if the exposure is
not current.
L Ve
We have always reimbursed a Blood Lead Test evenn though a FEP Test was not
recorded as having been done.
Sincerely,
i // : 74
Ruth S. Range, M.S., Chief
Regional: Operations Section
- Child Hehlth and Disability
Prevention Branch
* %
COUNTY OF LOS ANGELES © DEPARTMENT OF HEALTH SERVICES
313 NORTH FIGUEROA STREET @ LOS ANGELES, CALIFORNIA 90012 e (213)974-8591
July 11, 1989
TO: Ruth Range
FROM: Arthur D. Lisbin, M.D. jd
SUBJECT: LEAD TESTING
The recent report by the State Lead Poisoning Prevention
Project indicated that the Free Erythrocyte Protoporphyrin
(FEP) test was not a good screening test for lead poisoning.
Their recommendation was that in suspected cases, a blood
lead level should be drawn rather than an FEP.
The present CHDP Medical guidelines state that an FEP must
be done prior to a Blood Lead Level Determination. In view
of the recent report of the State Task Force I recommend
that the medical guidelines be revised and the FEP test removed
as a test for lead poisoning. op a
ADL: oP
cc: Srinivasa Murthy, ‘M.D. : “2
Sidney Smith, M.D. 5 ‘a,
® § =
a
STATE OF CALIFORNIA—HEALTH AND WELFARE AGENCY GEORGE DEUKMEJIAN, Governor
DEPARTMENT OF HEALTH SERVICES
714/744 P STREET
SACRAMENTO, CA 95814
(916) 322-4780
February 15, 1990
Barbara Allen, M.D., Director
Alameda County CHDP Program
499 - 5th Street
Oakland, CA 94607
Dear Dr. Allen:
Your letter requesting approval to perform blood lead level determinations on
high risk Alameda County residents nine months to six years of age has been
received. An FEP is no longer required before a blood level test will be
reimbursed.
The program has always promoted lead testing in children whose histories
indicated they are at risk for lead poisoning. Will the criteria used to
determine the level of risk of children be those listed in the letter?
Reimbursements will be approved only when the blood test is.part of a complete
Child Health and Disabiliey.) Prevention (CHDP) health assessment.
oy SWE at 5 ee
Please keep us tnitormed of She number of chilaigh you plan to test and any
other” specific risk criteria to be used.
207%
ry H. Cumming, Ph.D. EH
ild Health and Disability
Prevention Branch
~i he ees Xo EY -
~ AE, EEA
(
ALAMEDA COUNTY . 1 ®
HEALTH CARE SERVICES
AGENCY
DAVID J. KEARS, Agency Director
AGENCY HEADQUARTERS
CHILD HEALTH & DISABILITY PREVENTION PROGRAM 499 Fifth Street
Qakland, California 94607
(413) 268-2626
February 5, 1990
Gordon C. Cumming, PhD, Chief
child Health & Disability Prevention Programs Branch
california Department of Health Services
P. O. Box 942732
714 P Street, Room 708
Sacramento, CA 94234-7320
Dear Dr. Cumming:
Per CHDP Program Letter #86-19, our program is requesting approval for CHDP
providers in Alameda County (including the City of Berkeley) to screen routinely
the following population using blood lead determinations directly, rather than
first screening for FEP:
High risk Alameda County residents including the City of Berkeley
between 9 months to 6 years of age.
In 1986, a law was enacted commencing with Section 3097 of the Health &
Safety Code which established the Childhood Lead PSisoning Prevention Program
(CLPPP) and mandated that the Department of Health” Services (DHS):
* conduct childhood lead screening programs in three different
geographic areas of the state (urban northern, urban southern, and
rural central valley) that will permit the estimation of the extent
and causes of childhood lead poisoning in high-risk target areas in
California;
x analyze information collected, design and implement a program of
medical follow-up and environmental abatement and follow-up that will
reduce the incidence of excessive childhood lead exposures in
California;
* register cases of elévated blood 185d levels, defined as 25 or more
micrograms of lead per deciliter *{>25 ug/dL], and 35 or more ug/dL
erythrocyte protoporphyrin (EP) levels [>35 ug/dL] in children and
adults reported by law to the DHS by clinical laboratories; and
* submit a policy report containing CLPPP findings to the
Legislature with recommendations for the future prevention of
childhood lead poisoning in California.
One of the study sites was Oakland because it met the set of criteria
established by DHS. These criteria included:
x proportion of pre-1950 housing in excess of 60%;
* children aged 1-5 living in at least 10% of homes;
* presence of industrial lead emitters;
x proximity to freeways and arterials;
* ethnic factors predisposing to lead exposure (such as the use of home
remedies containing lead); and
* household income.
The results of the study showed that lead poisoning in Oakland children
is a public health crisis. Specifically, in Oakland, 1.3% of the children
examined had blood lead levels >25 ug/dL; 19.1% had blood lead levels 215 ug/dL.
It is estimated that 770 Oakland children 9 months to 6 years of age and eligible
for a CHDP exam would have blood lead levels > 15 ug/dL (Estimates are based on
1989 population estimates of children living in census tracts where 60% of the
housing was built prior to 1950). In addition, the CLPPP studies demonstrate
that the sensitivity of EP in detecting blood lead is extremely poor. If the
EP test had been used to screen children in the Oakland studies, 20% of the
children with blood lead > 25 ug/dL would have been falsely misclassed as
negative, and could suffer impairment in neuro- behavioral function persisting
into adulthood. The CLPPP report recommends screening: all at-risk children with
blood lead determination according to age and frequency recommendation of CDC.
we : ht
Bs a result of the CLPPP study, Dr. Kenneth Kizer' has made available to
us technical consultants, Dr. Lynn Goldman, Chief of the Environmental
Epidemiology and Toxicology Section and Dr. Mary Haan, Program
Director/Epidemiologist of the Childhood Lead Poisoning Prevention Project in
that Section. They are assisting us to initiate the development of an effective
lead screening, diagnosis, treatment, abatement and community education plan.
The screening component provides for blood-lead determination by venipuncture
of all at-risk Oakland children, 9 months to 6 years of age.
We would like to begin to pilot this program to reduce blood lead levels
in Oakland children. Not only are we planning an intensive screening program
of eligible CHDP children, but we are requesting measurement of blood lead levels
directly via venipuncture rather than an EP. NF
hist
de
Since we anticipate beginning this campaign in late March or early April,
we are requesting your approval at your earliest convenience for the screening
component for CHDP eligible children.
Sincerely,
Sti Ll, rd
Barbara Allen, M.D., Director
Alameda County CHDP Program
oc; Mary Haan, PhD.
Carl L. Smith, :M.D.
Martha Bureau, R.D.,M.P.H.
Carol Brown, P.H.N.
Verdie L. Thompson, R.N., B.S.N., M.S.N. ..
Deis +f fra :
Ns
CAR
iy A
3 hive
vo h et
Ar x
CUMMING/2/90
&
STATE OF CALIFORNIA—HEALTH AND WELFARE AGENCY EDMUND G. BROWN JR., Governor
DEPARTMENT OF HEALTH SERVICES
714/744 P STREET
SACRAMENTO, CA 95814
(916) 322-4780 March 24, 1982
CHDP Program Information Notice #82-E
To: Community Child Health and Disability Prevention Program Directors
and Deputy Directors
Subject: Lead Poisoning in Hispanic Children
We would like to call to your attention two recent articles in the "Morbidity
and Mortality Weekly Report', pointing to cases of lead poisoning in Hispanic
children from a folk remedy called azarcon.
Azarcon is an orange powder which is more than 85 percent lead tetroxide. It
is used in Mexico, and by many Mexican-Americans, as a remedy for "empacho."
Empacho is a term used to describe chronic digestive problems such as consti-
pation, diarrhea, loss of appetite, etc. Since many of the symptoms of empacho
are also symptoms of lead intoxication, a cycle may be started which may end in
severe lead poisoning. -
Parents need to know that azarcon is dangerous, it may cause empacho, and it is
especially bad for small children. Physicians and sanitarians who encounter a
case of lead poisoning should inquire whether the patient has been 'treated"
with this substance.
This information should be shared with CHDP providers and clinic staff who serve
Hispanic persons in your county. Providers should be aware of the possible use
of this substance, especially if lead poisoning is suspected in the screening
examination.
Dqrud A Co ierioetl OO
Siegried A. Centerwall, M.D., Chief
Child Health and Disability
Prevention Branch
Attachment
546 , MMWR November 6, 1981
Use of Lead Tetroxide as a Folk Remedy for Gastrointestinal lliness
in June 1981, a 4-month-old Mexican-American infant was admitted to Olive View Medi-
cal Center in Los Angeles County with a 12-hour history of vomiting and diarrhea. Initially, the
stools were watery and green; however, later bouts of diarrhea contained fresh blood. The
boy weighed 5.85 kg; his temperature was 99.5 F (37.5 C) (rectal); heart rate, 148/minute;
and respiratory rate, 40/minute. His abdomen was slightly protuberant and soft and the liver
edge and spleen tip were palpable. The child was active and playful and showed no other ab-
normal signs.
An X ray of the abdomen revealed a radio-opaque substance in the stomach. Gastric
lavage was performed immediately, and orange particles were observed. Orange particles
mixed with blood had appeared in stools passed on the day of admission. The mother repeat-
edly denied having given any medicinal substance to the baby but when the potential danger
of this unknown substance was explained, she admitted that a baby healer had given the
infant an orange powder known in Mexico as azarcon.
The bloody diarrhea gradually subsided over a period of 4 days and when the baby
showed no other evidence of poisoning, he was discharged on June 10.
An evaluation of the gastric aspirate revealed lead levels of 29,500 ug/L. Blood lead levels
on June 11 and June 22 were 45 pg/dL and 27 pg/dL, respectively. Atomic absorption analy-
sis of the substance by the Food and Drug Administration (FDA) determined that it was lead
tetroxide (Pb,0,), and had a total! lead content of 86%.
At 2 local county clinics, pa-icnts and their families were questioned about azarcon. Many
were aware of the substance, and related that it is used in small doses for empacho (chronic
indigestion) and other gastrointestinal ilinesses. It is readily available and a sample purchased
recently in Tijuana, Mexico, was identified as lead tetroxide by FDA analysis.
It is unknown at this time how common the use of azarcon is. A survey is currently in prog-
ress to determine its availability and use in Los Angeles County.
| Reported by KK Vashistha, MD, UCLA; B Agee, MD, S Fannin, MD, S James, A Martinez, G Ramirez, S
| Tilsen, Los Angeles County Dept of Health Svcs; DB Barr, M Luke, Food and Drug Administration; Envi-
ronmental Health Svcs Div, Center for Environmental Health, CDC.
- -g
. Vol. 30/No. 43 MMWR 547
Lead Tetroxide — Continued
Editorial Note: Children are exposed to lead from many sources, some of which may be
unusual or occur infrequently. This is the first report CDC has received of azarcon as a source
of childhood lead toxicity. The major sources of lead available to children are lead-based
paint, soil and dust contaminated by lead-based paint, land used by lead-related industries,
and lead deposits from automobile emissions and industrial air pollution. Other common,
lower-dose sources include food, air, and water. k
Distribution of lead tetroxide for consumption as a cure for gastrointestinal illnesses is of
substantial concern. Authories in areas with Hispanic populations should be alert to this poten-
tial public health hazard. As illustrated above, parents are often reluctant to admit — especially
to physicians — the use of folk remedies. :
Children with lead toxicity are usually asymptomatic or have non-specific symptoms. Be-
cause of this and the estimated high prevalence rate of the disease (1,00G to 3,000/100,000
children, ages 1-5), CDC recommends that all children, ages 1-5, be screened for lead toxici-
ty. In addition, medical providers should consider lead exposure when examining young
children.
ead Poisoning from Lead Tetroxide -
whip ed as a Folk Remedy — Colorado ’
Ps 1 th
Several comunity tlinics Yneide thq Denver metropolitan area have conducted lead-
screening programs among childrénjages B months to 5 years. These screening efforts were
initiated, in’ conjunction with the Epidemidlogy Division of the Colorado Health Department
and the Pediatric Microchemistry Laboratqry of the University of Colorado Health Sciences
Center, aftet 2 children. in Fort-Lupton were found to have lead poisoning 1 year ago as a
result of lead paint chip ingestion (7)q 33
On July 2497981, a '29-month-old Hispanic girl screened in Greeley was found to have a
zinc-protoporphyrin level of 19.1 pg/gm hemoglobin {normal <3.5), and a blood-lead level
of 69 po/dL (upper acceptable limit of <30). The child's house was found to be in good con-
dition, with no interior source of leaded paint. The exterior of the house had some peeling
leaded paint on the north wall, but there was no evidence that the child had unsupervised
access to this area. A capillary blood sample taken in September, immediately before the
child was given chelation treatment as an outpatient, had a lead level of 137 pg/dL; the lead
level fell to 44 ug/dL after treatment. On November 10, a repeat lead level was 61 ug/di, and
clinic staff revisited the home. After reading an article {2) reporting a Los Angeles case of
childhood lead poisoning caused by the folk remedy azarcon, the clinic staff asked whether
the girl had been treated by a folk healer for “empacho,” or chronic indigestion. The parents
acknowledged that the child was prone to empacho and that she had been treated with azar-
con on at least 3 occasions in the preceding 3 months. The child may also have been treated
with this remedy while living with her maternal grandmother in Mexico between the ages of 8
and 24 months. When the child was returned to her parents, the grandmother in Chihuahua
also sent along a bottle of azarcon.
The parents stated that the child had been given a dose (1/4 teaspoon) of azarcon early in
October because she had swallowed chewing gum. A blood-lead level measured approxi-
mately 3 days after she received this dose was 77 ug/dL. Laboratory analysis of the bright
orange powder from the bottle used to treat the child showed that the material was 93.5%
lead. :
Empacho is a popular, rather than scientific, term used to indicate a chronic digestive prob-
lem involving such diverse symptoms as constipation, diarrhea, nausea, vomiting, decreased
appetite, apathy, and lethargy. It is commonly believed to result from a bolus of food adhering
to the stomach wall.
Some Mexican-Americans in Colorado who have close ties with Mexico, where azarcon is
readily available, are familiar with this folk medicine as a treatment for both children and
adults with empacho. A more common remedy reported by several curanderos (folk healers)
a
648 MMWR January 8, 1982
Lead Poisoning — Continued
and their suppliers is azafran {American saffron), an orange herbal plant. Two samples of aza-
fran tested in Colorado contained no lead and could be distinguished easily from the orange
azarcon powder. Metallic mercury has also been used for the treatment of empacho by | Mexican-Americans (3).
{ Reported by A Ackerman, PhD, E Cronin, MD, D Rodman, RN, Sunrise Community Health Center, K Horan, K Hammond, MS, University of Colorado Health Sciences Center, L Aldaz, MSW, R Kellner, D Oui- mette, W Dunn, Colorado Health Dept; SL Fannin, MD, A Martinez, Los Angeles County Dept of Health Svcs, J Chin, MD, State Epidemiologist, California Dept of Health Svcs; Field Services Div, Epidemiology Program Office, Special Studies Br, Chronic Diseases Div, Center for Environmental Health, COC. Editorial Note: Recently, authorities in Los Angeles reported a second incident involving
azarcon. In mid-October, a 16-year-old Hispanic female was admitted to the Los Angeles
County/USC Medical Center with weakness, malaise, and jaundice. Blood studies revealed
7-8 hemoglobin, basophilic stippling, and Howell-Jolly bodies. Urinalysis showed 1+ protein
and trace sugar. Liver enzymes were slightly elevated. Heavy-metal poisoning was suspected.
However, this diagnosis was not confirmed because the patient left the hospital against medi- cal advice. It was learned later that the patient recently had been given azarcon and that the
substance was commonly used by her family. Investigation is continuing.
Lead poisoning from azarcon must now be considered in the differential diagnoses of
many complaints in patients of Mexican origin: anemia, abdominal pain, peripheral neuropa-
thy, encephalopathy, and renal disease. A particular concern is that azarcon might be given
for the symptoms of lead intoxication. The zinc protoporphyrin or free erythrocyte proto-
porphyrin tests are inexpensive, reliable blood tests for the effect of lead on porphyrin produc-
tion. A normal value precludes the presence of chronic increased lead absorption.
References
~~ 1. Two children with lead poisoning, Fort Lupton. Colorado Disease Bulletin 1981;20 {May 23). 2. CDC. Use of lead tetroxide as a folk remedy for gastrointestinal illness. MMWR 1981;30:548-7. 3. Geffner ME, Sandler A. Oral metallic mercury. A folk medicine remedy for gastroenteritis. Clin Pediatr 1980;19:435-7. : :
EEE ea aE EEE “n —— — - Ce mm — rere am ae des
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Lead f =
CHILD HEALTH AND DISABILITY PREVENTION
FISCAL YEAR 1984-85
FACT BOOK
I Prepared by Hh.
Michael Quinn, Research Analyst
Data Management & Policy Section
State of California hs Child Health and Disability
Department of Health Services Prevention Branch
Family Health Division + #fus Gordon Cumming, Ph.D., Chief
Nick Diez, Division Chief fe A, oh
a
Overview
Figure 1
Table 1
Table 2
Table 3
Figure 2
Table 4
Figure 3
Table 5
Figurs 4,
Table 6
Table 7
Table 8
Figure 5
Table 9
Table 10
Addendum
TABLE OF CONTENTS
0:9 3018.9. 4.90.2. 0.0 00.0 90 4l8.360.8 80 SVE PET EEL 08 CARNES Ew
CHDP Health Assessments by Funding Source, Fiscal Year
1875-78 Thvough 1984-85, ........ coisas oa
Number of Children Receiving CHDP Health Assessments by Type
of Assessment or Test, Fiscal Year 1984-85 ..................
Number of Immunizations Given by Type of Immunization,
Fiscal ¥ear JOB. BD ss een te a ey ia
Number and Percent of Children Served by Funding Source,
FiscaliYear 1OR4-BD tt neh cinnen nse sssivne Bey
Age (In Years) of Children Participating in the Child Health and
Disability Prevention Program, Fiscal Year 1984-85............
PAG oims ins webs ate i A a aN ae eae a TE
Ethnicity of Children Participating in the Child Health and
Disability Prevention Program, Fiscal Year 1984-85............
Number and Percent of Children Receiving CHDP Services by
Ethnicity, Fiscal Year 198485", ............... Ser
Gender of Children Participating in the child; Health and
Disability Prevention Program, Fiscal Year 1984- 85. FER
Ty
Number and Percent of Children Receiving CHDP- Services by
Gender, Fiscal Year 1984-85 , .. ... cc... ive rivnniiv ils
CHDP Provide: Type and Dollars Paid for Fee-for-Service Claims,
Fiscal Xear 1088-85... .. ovens sansin srt cirsine vs vs
CHDP Estimated Program Expenditures (in Millions, Fiscal
Year 1985-86). vee ruin ade.
Child Health and Disability Prevention Program, CHIC Claims
Processing, Fiscal Year 1985- TR i smi vn say
: LA #4 an i - ¥
Children Receiving CHDP Soria oy County of Patient
Residence, Fiscal Year 1084-8... uur ors i ane abi
Recent Trends in Medi-Cal: California State (1977-1985) and
County (1982-1984) Populations , ........ coves vunuvivii.
12
13
é »
OVERVIEW
The Child Health and Disability Prevention Program (CHDP) is a public health well child program that reimburses health assessments for the early detection and prevention of diseases and disabilities in children. Since the program’s creation in 1973 (AB 2068), the number of children served has continued to increase. (Figure 1)
The CHDP Program offers health assessment services including health history and physical examinations, nutritional and dental assessments, vision, hearing, and tuberculin tests, a variety of laboratory tests (such as blood, urine), and immunizations. (Tables 1 and 2)
The CHDP target population includes:
(1) Medi-Cal eligible children from birth to 21 years of age; (2) children from families whose income is at or below 200 percent of the MBSAC poverty level, (a) 0—13 months of age, (b) first grade enterers and (3) Head Start and State preschool children. Medi-Cal eligible children comprised 74.6 percent of the CHDP population served in Fiscal Year 1984—85. The state-funded children comprised 23.9 percent of the population served. (Table 3)
In Fiscal Year 1984-85, 32.6 percent of the children receiving CHDP services were under 1 year of age. Over 86 percent of the children served were 6 years of age or younger. Only about 5.4 percent of the children served were 13 years of age or older. (Figure 2, Table 4)
Minority children constituted 62 percent of those served. Only 24.5 percent of the population served was reported as white. The unknown or not-reported ethnicity was 10.1 percent. (Figure 3, Table 5)
A variety of providers offer services to children eligible for CHDP services. These providers are enrolled at the county level. The majority of providers (77 percent) in Fiscal Year 1984-85 were either group or solo physicians. (Table 7) Ox ob . EX
-
Estimated CHDP expenditures for Fiscal Year 1985-86 totalled $61.786 million. Approxi- mately’ 95 percent of that amount was either paid for fee-for-service claims or was allocated to local programs. State money constituted slightly over “half of the expenditures (53.6 percent), federal money constituted 45.2 percent, and county money constituted 1.02 percent (May 1986 estimate). (Table 8)
As of July 1986 a total of 967,051 claims were processed in Fiscal Year 1985-86. Medi-Cal claims amounted to 69.65 percent and state-funded claims amounted to 26.01 percent. The percent of Medi-Cal claims decreased by approximately 4 percent from Fiscal Year 1984-85 to Fiscal Year 1985-86. The number of state-funded claims continues to increase as those children ages 0—13 months continue to receive CHDP services. The decrease in Medi-Cal funded claims processed seems to reflect the general trend in California of a decrease in Medi-Cal eligibles as a percent of total population. (See addendum: Recent Trends in Medi-Cal: California State (1 977-1985) and County (1982+:1984) Populations.)
28 4 {3X8
v
The Fiscal Year 1984-85 summary file is prepared by accumulating the services received by each individual child as indicated on the PM-160 claims and billing form. CHDP services can be billed for up to one year after date of services; therefore, a small number of claims are billed after closure of the annual data file. Total omitted claims or reporting errors contribute less than 1 percent of the data file.
4 nl
Figure 1
CHDP HEALTH ASSESSMENT BY FUNDING SOURCE
Fiscal Year 1975-76 Through 1984-85
800
a
700
7p]
-
2
Es 600
wi
5. S00
< 3
x §
bs n 400
J 0]
WE 300
33.
®)
cc
Ww 200
om
=
>
2 100 £ 0+ 7 1 ST T 1 ny T T 75/76 76/77 77/78 78/79 79/80 80/81 81/82 © 82/83 83/84 84/85
Ye
OD Total X Medl—Cal v '’State~Funded
FUNDING SOURCE
1983-84 to Fiscal Year 1984-85. (See addendum: Recent Trends in Medi-Cal: California
State (1977-1985) and County (1982— 1984) Populations.)
Table 1
- NUMBER OF CHILDREN RECEIVING CHDP HEALTH
ASSESSMENTS BY TYPE OF ASSESSMENT OR TEST
Fiscal Year 1984-85
Number of
Type of Assessment Children Receiving
or Test Assessment or Test
History/Physical 576,913
Dental 556,169
Nutritional 574,406
Vision 216,627
Hearing 200,957
Blood 331,971
Urine (Dipstick) 214,938
1.8. 251,134
Sickle Cell 811
Lead:FEP 283
Lead:Blood } F352
VDRL | 2225
G.C. Culture 17622
PAP Smear + 1,115.
PKU:Blood £231
Urinalysis (Complete) 27,519
All children receive a CHDP complete history and physical examination plus a variety of other
assessments depending on age requirements. Several typesiof tests are given at appropriate
times and ages. x
Table 2
NUMBER OF IMMUNIZATIONS GIVEN
BY TYPE OF IMMUNIZATION
Fiscal Year 1984-85
Number of
Type of Immunization Immunizations Given
Total 719,047
Polio 314,682
DPT/TD 333,580
MMR 58,944
MUR 574
MR 946
Mumps 3,710
Measles 3,444
Rubella 3,167
CHOP pays for an administrative fee and vaccine cost for 3 variety of immunizations. DPT/TD and Polio are the most administered immunizations. (MMR stands for Mumps, Measles, and Rubella; MUR stands for Mumps and Rubella; and MR stands for Measles and Rubella.)
Table 3
NUMBER AND PERCENT OF CHILDREN —,
SERVED BY FUNDING SOURCE
Co
Fiscal Year 1984-85
Number of
Funding Source Children Percent
Total 589,436 100.0%
Medi-Cal 440,084 74.6
State-funded (200% MBSAC) 141,009 23.9 PHP/Information Only 8,343 - 1.5
Waits
pe
PN
2 hed”
Approximately 75 percent of all children served in Fiscal Year 1984-85 were funded by Medi-Cal. Children who receive state funding were from families with incomes less than 200 percent of the State AFDC poverty level who were also either entering school, low birth weight infants, or children enrolled at a Head Start or State Preschool program. (PHP stands for Prepaid Health Plan; MBSAC stands for Minimum Basic Standard of Adequate Care.)
igi a
AGE (IN y = OF CHILDREN PARTICIPATING IN THE
CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
N
U
M
B
E
R
OF
C
H
I
L
D
R
E
N
(T
ho
us
an
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ri — 1 || 1 1 1 |] SE 1 1 i : § GEESE | i i i i
2 3 4 5 6 7 8:9 10 13 12 13 14.15.16 17. 18 19 20UNK
AGE IN YEARS
4
1
Figure 2 illustrates children receiving CHDP services by age for Fiscal Year 1984-85. Of a total of 589,436 children, almost one-third (32.6 percent) were under age 1; 52 percent were 2 years and under; 86 percent were 6 years and under; and only 5.3 percent were 13 years or older, Jl
“Ha 4, ;
Table 4
NUMBER AND PERCENT OF CHILDREN RECEIVING CHDP SERVICES BY AGE
Fiscal Year 1984-85
Age Number of Age Number of
in Years Children Percent Children Percent
Total 589,436 100.0%
A
O
W
O
O
N
O
O
LH
L
W
N
tb
192,171 32.6 5: 11
77,851 13.2 12
41,467 7.0 13
37,101 6.3 14
57,886 9.8 15
62,635 10.6 16
38,120 6.5 17
13,445 2.3 : 18
8,817 1.5 19
8,374 1.4 20
7,486 1.3 Unknown
J
l
L] igi c wh
erry OF CHILDREN snnncrann
CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
Fiscal Year 1984-85
N
U
M
B
E
R
OF
C
H
I
L
D
R
E
N
(
T
h
o
u
s
a
n
d
s
)
rs RS
i ] I | | ¥ 1] 14
American Mexican-
Indian Asian Filipino American White Other Unknown
ETHNICITY
Figure 3 illustrates the ethnicity of children receiving CHDP services in Fiscal Year 1984-85.
Approximately 61 percent of all children seen are of a minority group. The largest group is
Mexican-American (approximately 39 percent of all children served). Other ethnicity and
unknown ethnicity total about 14 percent.
Table b
NUMBER AND PERCENT OF CHILDREN RECEIVING
CHDP SERVICES BY ETHNICITY
Fiscal Year 1984-85
Number of
Ethnicity Children Percent
Total
American Indian
Asian
Black
Filipino
Mexican-American
White
Other
Unknown
N
U
M
B
E
R
OF
C
H
I
L
D
R
E
N
(
T
h
o
u
s
a
n
d
s
)
300
280
260
240
220
200
180
160
140
120
100
Figure 4
NUMBER OF CHILDREN RECEIVING
CHDP SERVICES BY GENDER
Fiscal Year 1984-85
T ; T CE T
Female Male EW Unknown
GENDER
Table 6
NUMBER OF CHILDREN RECEIVING
CHDP SERVICES BY GENDER
Fiscal Year 1984-85
Gender “Frequency : 53 Percent
Total : 589,436 100.0%
Female 286,214 48.5
Male 296,426 50.3
Unknown 6,796 1.2
Table 7 . CHDP PROVIDER TYPE AND DOLLARS
PAID FOR FEE-FOR-SERVICE CLAIMS \
Fiscal Year 1984-85
Children Receiving
Provider Type CHDP Services . Amount Paid
Totals 589,436 $34,259,041
County Hospital (outpatient) 15,538 863,306
Community Hospital (outpatient) 6,786 365,537
Organized Outpatient Clinics 25,667 1,513,783
OEOQO Clinics 4,946 282.722
Private Corporations 34,950 2,141,158
Nonprofit Corporations 21,842 1,242,817
Professional Societies 505 28,110
Day Care Centers 1,018 56,159
Schools 23,598 1,176,535
Prepaid Health Plans 1,059 55,381
Physicians Group 97,882 5,914,697
Physicians Solo 240,140 14,998,325
Optometrists 133 8,840
County Health Departments i 101,271 TH 5,260,363
Other 6082 i 348,458
- Unknown | 80187: "} 2,850
Of the total 3,337 CHDP providers in Fiscal Year 1984-85, 2,546 (77 percent) were either
group or solo physicians. These accounted for $20,913,022 (61 percent) of the total fee-for-
service dollars paid to providers. County health departments accounted for 155 (4.6 percent)
of the providers and $5,260,363 (15 percent) of total fee-for-service dollars paid to
providers. add ay Ty.
Table 8
CHDP PROGRAM EXPENDITURES (IN MILLIONS)
Fiscal Year 1985-86 (May 1986 estimate)
Total Percent Fund Expendi- of Total Source of Funds
Expenditure Categories tures Expendi-
(estimate) tures State Federal County
Total, FY 1985-86 $61.786 100.0% $ 33.159 $ 27.998 $ .629
State Operations 3217 5.2 1.278 1.939 (—)
(Administration) (1.830) (3.1) (.772) 1.158 (=)
(Claims Processing) (1.287) 52.1) (.506) (.781) (—)
Health Assessments 44.217 71.6 27.878 16.339 (-)
(Medi-Cal [EPSDT]) (32.678) (52.9) (16.339) (16.339) (—)
(Non-Medi-Cal) (11.539) (18.7) (11.539) (—) (—)
Reimbursements to Local
Governmental Agencies 14.352 23.2 4.003 9.720 629
(Schools) (.383) (0.6) (.383) (=) (-)
(County CHDP Programs) (13.969) (22.6) (3.620) (9.720) (.629)
*Includes direct, indirect, and data processing costs.
Table 8 depicts the estimated CHDP expenditures for Fiscal Year 1985-86. Only 5.2 percent
of the total budget was expended for state operations. Almost 72 percent of the total funds
available were paid for fee-for-service claims from recipients. The remaining 23.2 percent was
allocated to the counties for their operating expenses (quality assurance, outreach, education,
etc.).
Figure 5
CHILD HEALTH AND DISABILITY PREVENTION PROGRAM . CHIC CLAIMS PROCESSING
Fiscal Year 1985.1 986
\
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4
; July 1985 through June 1986 V7] Medi-Cal NY State = W/ Unpaid
token : RINE
FUNDING SO URCE"
COUNTY OF PATIENT RESIDENCE
Table 9
CHILDREN RECEIVING CHDP SERVICES
Fiscal Year 1984-85
Children
Children County Receiving CHDP Percent County Receiving CHDP Percent Services
Services
Total 589,436
100.0%
Alameda 20,076 34 Placer 3,228 0.5 Alpine 49 0.0 Plumas 433 0.1 Amador 619 0.1 Riverside 20,517 3.5 Butte 5,292 0.9 Sacramento 28,901 49 Calaveras 855 0.1 San Benito 1,247 0.2
Colusa 396 0.1 San Bernardino 27,600 4.7 Contra Costa 9,989 1.7 San Diego 37,928 6.4 Del Norte 974 0.2 San Francisco 11,812 2.0 El Dorado 1,586 0.3 San Joaquin 18,731 3.2 Fresno 30,737 5.2 San Luis Obispo 3,489 0.6
Glenn 967 0.2 San Mateo 5,482 0.9 Humboldt 4,802 0.8 Santa Barbara 7,285 12 Imperial 4,068 0.7 Santa Clara 19,620 33 Inyo 436 0.1 Santa Cruz 4,867 0.8 Kern 18,880 3.2 Shasta 4,145 0.7
Kings 3,342 0.6 Sierra 80 0.0 Lake 1,623 0.3 Siskiyou 1,366 0.2 Lassen 911 0.2 Solano 4,687 0.8 Los Angeles 181,651 30.8 Sonoma 4,725 0.8 Madera 3,901 0.7 Stanislaus 8.424 1.4
Marin 1,471 0.2 Sutter 2,207 0.4 Mariposa 267 0.0 Tehama 1,182 0.2 Mendocino 2,435 0.4 Trinity 321 0.1 Merced 9,289 1.6 Tulare 13,291 2.3 Modoc 346 0.1 Tuolumne 1,190 0.2
Mono 81 0.0 Ventura ie 7,718 1.3 Monterey 7612 1.3 Yolo 3,280 0.6 Napa 1,391 0.2 Yuba 2212 0.4 Nevada 1,564 0.3 City of Berkeley 440 0.1 Orange 27,383 4.6 Unknown 42 0.0
Source: PM 160 Claims and Billing Form
Fiscal Year 1984-85 Summary File
-1%.
* | able 10 S
CHDP SCHOOL REPORT:
ALL REPORTING SCHOOLS—PUBLIC AND PRIVATE
Number of Children Enrolled in First Grade,
Percent with Health Certificates, Percent with Waiver, and Percent
with no Certificate or Waiver
Fiscal Years 1980-81 Through 1985-86
First Percent of First Grade Children With: : Fiscal Grade Health Certificate No Certificate Year Enrollment Certificate Waiver or Waiver or Waiver
1980-81 331,075 70.6% 4.3% 74.9% 25.1%
1981-82 337,211 73.0 4.3 77.3 22.7
1982-83 342,886 74.5 4.3 78.8 21.2
1983-84 360,341 753 4.4 719.7 20.3
1984-85 371,386 76.3 4.2 80.5 18.5
1985-86 391,802 76.9. 4.2 81.1 18.9
Source: PM 272, CHDP Annual School Report Form
The percent of children enrolled in first grade with either a health certificate or waiver as reported by public and private schools has increased 6.2 percent from 74.9 percent in Fiscal Year 1980-81 to 81.1 percent in Fiscal Year 1985-86.
The. percent of children with health certificates has increased from 70.6 percent in Fiscal Year 1980-81 to 76.9 percent in Fiscal Year 1985-86, a 6.2 percent increase.
32.
From 1977 to 1985 the percentage of Medi-Cal eligibles decreased in relation to the State's population going from 13.2 percent in 1977 to 10.9 percent in 1985 (Table 1). The 1977 percentage of Medi-Cal eligibles represented the highest percentage relative to the State's population since the Medi-Cal Program's inception in 1966.
TABLE 1
MEDI-CAL PROGRAM
CALIFORNIA STATE POPULATION AND
NUMBER AND PERCENT MEDI-CAL ELIGIBLES
1977-1985
California Medi-Cal Percent of
Year Population Eligibles2 State Population
1977 21,890,000 2,899,918 13.2
1978 22,839,000 2,922,265 12.8
1979 23,255,000 2,804,343 12.1
1880 23,771,000 2,959,340 12.4
1981 24,216,000 3,087,778 12.8
1982 24,698,000 3,025,773 12.5
1983 25,186,000 2,804,720 11.1
1984 25,622,000 2,826,933 = 11.0
1985 26,365,000 2,878,765 10.9
July 1
2 Monthly average
During this time period the State's population increased 20.4 percent to a grand total of 26,365,000, while the number of Medi-Cal eligibles decreased 21,153 ending with a total
of 2,878,765 in 1985.
Source: State of California, Department of Finance, Population
Estimates of California Counties, July 1, 1980 to July 1,
1985, Report 84 E-2, February 1986: Intercensal
Estimates of Total Population, California Counties
Report 1 and 70-80, March 1982.
California State Department of Health Services, Medi-Cal
Certified CID Eligibles, Calendar Years 1977-1985.
MEDI-CAL REPORTS, “Recent Trends in Medi-Cal:
California State (1977-1985) and County (1982-1984)
Populations.” he
Number: 86—01121 (Feb. 1986). :
“13 -
® / cid I, o
-
CHILD HEEALTE AND DISABILITY FREVENTION PROGRAM
REGULATION
EXCERPTED ROM TEE
CALIFORNIA CODE ~rF 1!
TITLE 17 (PUBLIC HEZALTH)
Thts is the main body of regulations which implement,
interpret or make specific the enabling legislation of
the Child Health and Disability Prevention Program
(Sections 320 et seg. , Health and Safety Code).
Department of Health Services
: Family Health Division ;
Child Health & Disability Prevention Branch
714 P Street
Sacramento, CA" 95814 -
~N
July 1990
SUBCHAPTER 13. CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
Article 1. Definitions
6800. Health Assessment.
(a) "Health assessment" means the following:
(1) A comprehensive health and developmental history, and a
physical examination.
(2) Appropriate health screening procedures and immunizations.
£Y) Evaluation of results in terms of needed diagnosis and
reatment.
(4) Providing the person screened with a copy of the results and
an explanation of their meaning.
(5) Health education appropriate to the person's age and health
status., including anti-tobacco use education.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code and Section 12, Assembly Bill 75 (Chapter 1331, Statutes of 1989).
References Sections 321.2," 324, and 24165.3 of the Health and
Safety Code.
5801. Community.
"Community" means an individual county, or a city and county, or counties acting jointly, or a City which operates an independent health agency. Inthe instance of a city Providing the services described in this subchapter, the powers granted a governing body of a county to operate a child health and disability prevents: program shall be vested in the governing body of that city.
NOTE: Authority cited: Sarcrtions 208 and 321, Health and Safety Code.
Reference: Sections 320, et seq., Health and Safety Code.
6804. Contract Counties.
"Contract counties" means those counties which contract with the Department for health services and which have not elected to provide the services themselves. The Department is responsible for the child health and disability prevention programs in those counties.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: Sections 320, et seqg., Health and Safety Code.
®
»
s 5806. Department.
"Department" means the State Department of Health Services.
NOTE: "Authority cited: Sections 208, 320.2 and 321, Health and
Safety Code.
Reference: Sections 320, et seq., Health and Safety Ccde.
: ®
»
6808. Diagnosis.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code.
Reference: Sections 320, et seqg., Health and Safety Code.
6810. Director.
"Director" means the Director of the State Department of Health Services, unless otherwise specified.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference Section 320, et seq., Health and Safety Code.
4 ph
6812. Governing Body.
"Governing Body' means, except where indicated otherwise in this
subchapter, the county board of supervisors, or boards of superviscrs
ln the case of counties acting jointly or the city council in the
case of a city.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code.
Reference: Sections 320, et seqg., Health and Safety Code.
.
4 %
6813, Initiation of Treatment.
"Initiation of treatment" means the first encounter for treatment of
the medical and the dental problems disclosed during the health
assessment.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code.
Reference: Section 323.7, Health and Safety Code.
-
6814. Medi-Cal Beneficiary.
(a) "Med1-Cal beneficiary" means an individual under 21 years of age who 1s eligible for and Certified to receive services under Provisions of the California Medical Assistance Program (Chapter 7. 0f Part'3 of Division 9 of the Welfare and Institutions Code, beginning with Section 14000). Medi-Cal beneficiaries include:
(1) Persons who are certified eligible to receive cash grants under one of the public assistance programs.
(2) Persons who are certified eligible to receive medically needy or medically indigent Medi-Cal benefits.
(3) Other persons who are certified eligible to receive noncash grant Medi-Cal benefits. Other persons include the following:
(A) Children not in school and not in training.
(B) Persons receiving in-home supportive services.
(C) Persons who have lost AFDC eligibility, but are continuing tO receive Medi-Cal benefits for four months from the date of lost eligibility.
(D) Persons who were discontinued from cash grants solely due to a 20 percent Social Security increase in 1977.
NOTE: Authority cited: Sections 208 and 321. Health and Safety Code.
Reference; Sections 320, et seqg., Health and Safety Code. -
»
10 %
6816. Person.
"Person" means anyone from birth to 21 years of age eligible to
receive services specified in this subchapter. Persons include
newborns, infants, children, youth, emancipated minors, young
adults and adults. In those instances where the person is not an
adult or an emancipated minor, "person" means the person, or
his/her parent(s) or guardian(s).
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code.
Reference: Sections 320, et seqg., Health and Safety Code.
11 DN
6318. Screening.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code.
Reference: Sections 320, et seg., Health and Safety Code.
(4
12 >
6820. Advisory Boards.
(a) Membership. Membership in an advisory board shall be as
follows:
(1) Members appointed to the local advisory board by the local
governing body shall include, but not be limited to, individuals
whe, at the time of their appointment, are representatives of
health professions concerned with child health, school health
personnel and parents of children eligible to receive services
under provisions of this subchapter, whether or not the services
are eligible for state reimbursement.
(2) The governing body may recognize individuals as alternates
who have professional or parent qualifications equivalent to that
of the member.
(3) The governing body shall not appoint any employee of the
local health department to the advisory board, except that the
director and deputy director of the community child health and
disability prevention program shall be ex officio, nonvoting
members of the board.
(4) Individuals appointed to the advisory board as parents of
children eligible to receive services shall neither be emploved
by an individual or an agency providing health services to the
public for fee, nor be a provider of health services to the
public for fee.
(Db) Responsibilities. The local advisory board shall be
responsible for the reviewing, advising and reporting functions
related to the community child health and disability prevention
program as specified in Section 321.7, Health and Safety Code.
The advisory board may also advise the local governing body and
appropriate governmental agencies on health matters additional to
the community child health and disability prevention program,
such as maternal and child health in general.
(c) Tenure. Members of the advisory board shall serve at the
pleasure of the appointing authority for a term of three years,
except that one-third of the members first appointed in each
jurisdiction shall serve for three years, one-third of the
members for two years and one-third of the members for one year.
(d) Meetings. The advisory board shall meet at least twice each
year, once before March 1, and once after March 1 but before
September 1. In addition, the board shall meet on the call of
the chairperson of the board or on the call of one-third of its
members. Public notice shall be given of the date, time and
location of each meeting in advance of the meeting. Meetings
shall be open to the public.
(e) Reimbursement. Advisory board members and alternates shall
serve without compensation, except that members, and alternates
14 >
when acting in lieu of members, shall be reimbursed under the
approved community plan for actual and necessary expenses
incurred in connection with the performance of their duties.
Parent members may additionally be reimbursed for their actual
and necessary costs of child care and lost wages.
NOTE: “Authority cited: Sections 208 and 321, Health and Safety
Code.
Reference: Section 321.7, Health and Safety Code.
’
15 ™
6822. Directcr and Deputy Director.
(a) Designation. Each governing body, except those in contract
counties whose programs are administered by the Department, shall
appoint a physician, licensed to practice medicine in California,
as Director, Child Health and Disability Prevention Program. The
director shall have administrative responsibllity for the
organizational unit concerned with child health in the local
health departzent as defined in Section 1102, Health and Safety
Code. If the director is an existing health official, the
director or local appointing authority shall also appoint a
Deputy Directer, Child Health and Disability Prevention Program,
with experience in the delivery of health services to children
and youth who is assigned to the organizational unit for which
the Director, Child HKealth and Disability Prevention Program, has
direct administrative responsibility.
(b) Responsibilities. The responsibilities of the director
shall include, but not be limited to:
(1) Developing and implementing the community child health and
disability prevention program plan and assuring its compliance
with federal and state regulations. To the extent possible, this
plan should relate to all community health services for children
and youth, and to the integration and coordination of these
services with the community's child health and disability
prevention prcgranm.
{2) Managing funds granted under the State-approved community
plan.
>
(3) , Completing all reports and maintaining all records required
by the Department.
(4) Providing support staff and services to the community child health and disability prevention advisory board.
(5) Preparing an annual report to the governing body.
(c) Reimbursement. The salary and necessary expenses of the community child health and disability prevention program director or deputy director may be reimbursed by the State under the approved community plan to the extent that the services are directly related to the community child health and disability prevention program. However, if the director is a health officer as defined in Sections 451, 502 or 940 of the Health and Safety Code, no funds from this program shall be used directly or indirectly for reimbursement of the health officer's services rendered to the program. If the director is an existing health official other than the health officer, the official's salary may be reimbursed to the extent the official renders services to the program as indicated in the program's approved annual plan and budget.
16 MN
6824. State and Local Responsibilities.
(a) Annual plan and budget. On or before March 15 of each vear, each governing body shall submit to the Department's Child Health and Disability Prevention Program the following:
(1) A summary of the previous fiscal year's activity ending the previous June 30.
(2) A summary of the current fiscal Year's activity from the previous July 1 to the date of the revised budget submittal. A Projection of activities from the date of the revised budget submittal through June 30 of the current fiscal year is desirable, but optional.
(3) A description of the community program to be offered the next fiscal year, including expected program performance goals and activities. Descriptive material submitted as part of a Previously state-approved plan need not be repeated. If the community child health and disability prevention program plan is part of the community's more comprehensive child health plan, the more comprehensive plan may be submitted in lieu of a separate community child health and disability prevention program plan.
(4) A budget for the next fiscal Year beginning July 1.
(A) The community child health and disability prevention program budget for the budget year shall be limited to those items, including equipment and remodeling, required to implement the plan approved by the Department's Child Health and Disability Preventiorr Program.
(B) If the amount appropriated in the State Budget Act and enacted into law for the budget year differs from the amount in the budget submitted by the Governor, each local governing body shall submit to the Department's child Health and Disability Prevention Program an additional revised Plan and budget that reflects the share of the reduction determined by the Director to Pe applicable to that community child health and disability prevention plan.
(5) A preliminary budget estimate for the following fiscal year beginning the following July 1.
(6) A current agreement between the community child health and disability prevention program and the county welfare department relating to the provision and documentation of child health and disability prevention services to Medi-Cal beneficiaries and setting forth the responsibilities of the community program and the county welfare department to assure adequate informing, outreach, referral and follow-up. ;
(7) Other information which may be required by the Department's Child Health and Disability Prevention Program.
~
18
}
(b) Informing Medi-Cal beneficiaries. Medi-Cal beneficiaries
shall be informed as follows:
(1) No later than 60 days following the date of a farily's
initial Medi-Cal eligibility determination or of determination
after a period of ineligibility, the family must be informed of
the availability of CHDP services including dental services.
This must be done in writing and using face-to-face contact by a
person who can explain these services and benefits. A family who
loses. and regains ‘eligibility more than twice within a
twelve-month period need not be informed more than twice in that
twelve-month period. Informing includes the offer of services,
assistance with scheduling appointments and transportation, and
documenting responses.
{2) If no member of an eligible family participates in the
program, the family must be informed in writing at least once
each year beginning October 1, 1980. Informing includes offering
CHDP services, offering assistance with transportation and
scheduling appointments, and documenting responses.
(3) Each of the following must be used to inform an eligible
family:
(A) Clear, nontechnical materials for those families who are to
be informed in writing.
(B) Procedures suitable for informing persons who are
illiterate, blind, deaf, or cannot understand the English
language.
(4) A family being informed about the program must be given the
following information:
(A) The benefits of preventive health and dental services.
(B) How medical and dental services can be obtained.
(C) How specific information can be obtained on the location of
the nearest providers participating in the program.
(D) The health assessment and dental services that are offered.
(E) A summary of the State's periodicity schedule.
(F) That recipients can receive both initial and periodic health
assessments and dental services according to the State's
periodicity schedule.
(G) That treatment services shall be provided for problems
disclosed during screening.
(H) That assistance in referral shall be provided.
1
(I) That assistance with transportation shall be provided if the Person requests it.
(J) That assistance in scheduling appointments shall be provided 1f the person requests this assistance.
(K) That as long as the person remains eligible for Medi-Cal, he Or she may request these services at any time in the future if the decision is postponed at the time of initial informing.
(L) That the person may choose to receive CHDP services from a provider of the person's choice, and that if the provider does not offer the full range of CHDP services specified in this subchapter, the person can receive the services not offered if the person makes a request to the community CHDP program or welfare department. If such request is made, assistance in scheduling appointments and transportation shall be offered, and the responses documented.
(M) That these CHDP services are available from approved providers at no cost to the family.
({C) Information and training for county welfare employees. Information and training for county welfare department personnel shall be as follows:
(1) The State Departments of Health Services and Social Services shall provide information, training and materials necessary to ensure that county social services and welfare eligibility personnel, and other appropriate welfare department employees, are fully informed as to the purpose, nature, scope and benefits of CHDP services.
(2) Such employees shall be trained in nethods of information dissemination that will encourage and motivate eligible individuals to make use of such preventive medical progranms.
(3) The provision of such training shall be verified in appropriate sections of the annual Plans submitted to the Department's Child Health and Disability Prevention Program by community child health and disability prevention programs.
(d) Information and training for local health department personnel. Information and training for local health department personnel shall be as follows:
(1) The Department shall provide such information, training and materials necessary to ensure that appropriate local health department personnel and other appropriate county and municipal employees are informed as to the purpose, nature, scope and benefits of CHDP services.
(2) Such employees shall be trained: in methods of information dissemination that will encourage and motivate eligible individuals to make use of such preventive medical programs.
5 hh
(3) The provision of such training shall be verified in
appropriate sections of the annual plans submitted to the
Department's Child Health and Disability Prevention Program by
community child health and disability prevention programs.
(e) Required services. Yach -community child health and
disability prevention program shall provide, in accordance with
thls subchapter, at least the following services:
(1) Outreach and health education., including anti-tobacco use
education required or available from the CHDP Program.
(2) Referral to dentist.
(3) Referral to a health assessment.
(4) Health assessment.
(5) Certification for school entry.
(6) Referral to diagnosis and treatment.
{7) Diagnosis and treatment.
{f) Records and information. Each community child health and
disability prevention program shall keep records and provide
information on the results of health assessments and follow-up to
diagnosis and treatment, and other data about the persons served
as may be required by the Department's Child Health and
Disability Prevention Program.
”~
(g) Other responsibilities. The Department shall provide the
following:
(1) Regulations and minimum standards for quality preventive
health services for children and youth., including anti-tobacco
use education guidelines.
(2) Consultation services on all aspects of community program
development.
(3) Appropriate data collection and reporting forms.
(4) Documentation and data, made available at the state or local
level, on all aspects of the program including:
(A) The results of informing services.
(B) The results of screening services.
(C) The results of diagnosis and treatment services.
(D) The results of anti-tobacco education services.
™
21
{5) Management reports for state and local program use.
(6) Reports required by the federal Early Periodic Screening
Diagnosis and Treatment Progran.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code and Section 12, Assembly Bill 75 {Chapter 1331, Statutes of
1589).
Reference: Sections 320, 321.2 {a)={(e), 324 and 24165.3 (cy,
Health and Safety Code.
.~
6826. State and Local Information and Training Responsibilities.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: Sections 320, et Seéq., Health and Safety Code. Répealer filed 11-28-76 as an emergency; effective upon filing (Register 7%, Ho. 48). A Certificate of Compliance must or emergency language will be repealed on 3-28-80.
23
6828. Sancticns for YNoncompliance.
(a) 1f the Chief of the State Child Health and Disability
Prevention Program determines that a reasonable period of
technical consultation and assistance has been provided or
arranged for by the State Child Health and Cisability Prevention
Program, and further determines that a community child health and
disability prevention program director fails to comply with any
state or federal law or regulation governing child health and
disability prevention services, or with the approved community
Plan, the Chief of the State Child Health and Disability
Prevention Program shall notify the local governing body in
writing of the specific areas of noncompliance. A copy of the
notice shall be sent to the community program director, the
county welfare department director, and to the local child health
and disability prevention program advisory board.
(b) If the local governing body fails to provide substantial
evidence to the Chief of the State Child Health and Disability
Prevention Program within 30 days that the community program
director is complying and shall continue to comply with the laws,
regulations and the approved community plan, the Director shall
convene a hearing for the community program to show cause why the
Director should not take action to secure compliance. The
Director shall invite the community child health and disability
prevention program's advisory board and other persons or
organizations interested in the community's child health and
disability prevention program to present comments at such
hearing. The Department shall give the community program,
concerned individuals and organizations, and the general public
at least 15 days notice of such hearing. :
(c) The Director shall consider the case on the record
established at the hearing and render findings and decision on
the issues within 30 days following the hearing. The findings
and decision shall be submitted in writing by the Director to the
local governing body. A copy of the notice shall be sent to the
community program director, the county welfare department
director, and to the local child health and disability prevention
program advisory board.
(d) If the Director determines that there is a failure on the
part of the community child health and disability prevention
program to comply with any state or federal law or regulation
governing child health and disability prevention services, or the
approved community plan, the Department may invoke any of the
following sanctions:
(1) Consistent with federal and state law, withhold part or all
of state and federal funds from such community until the local
governing body provides written documentation of compliance to
the Director.
(2) Bring an action in mandamus or such other action in court as may be appropriate to compel compliance.
(e) Nothing in this section shall be construed as relieving the local governing body of the responsibility to provide funds necessary to continue the child health and disability prevention Services required by Sections 320, et seq., Health and Safety Code.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: Sections 320, et seg., Health and Safety Code.
Article 3. ‘Eligibility for Services and Reimbursement
25. hy
6830. Eligibility for Services.
(a) Medi-Cal beneficiaries shall be eligible for periodic health
assessments, and for diagnosis and treatment, if necessary, in
accordance with the provisions of this subchapter.
(b) Any child (1) between birth and 90 days after entrance into
the first grade who is not a Medi-Cal beneficiary and (2) all
persons under 19 years of age whose family income is not more
than 200 percent of: the federal poverty level shall be
eligible for health assessments in accordance with the provisions
of this subchapter. Availability of services and reimbursement
for these services shall depend on the amount of funds
appropriated by the Legislature for the services as specified in
Section 6832 (Db).
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code and Section 12, Assembly Bill 75 (Chapter 1331, Statutes of
1389).
Reference: Section 323.7, and 24165.3(a), Health and Safety
Code.
A
26
6832. Eligibility for Reimbursement.
(a) The costs of periodic health assessments provided to
Medi-Cal beneficiaries shall be reimbursed by the State in
accordance with the schedule of maximum allowances specified in
Section 6868.
(b) If the amount of funds appropriated in the State Budget Act
are sufficient, the costs of health assessments provided to
(1) children between birth and 90 days after entrance into the
first grade, who are not Medi-Cal beneficiaries, and (2) "all
persons under 19 years of age whose family income is not more
than 200 percent of federal poverty level shall be reimbursed by
the State. To the extent that funds are not sufficient, these
costs shall be reimbursed only for those children who meet the
age and family income criteria defined by the Department's Child
Health and Disability Prevention Program.
(C) The costs of diagnosis and treatment services provided
to Medi-Cal beneficiaries as a result of health assessments shall
be reimbursed by the State in accordance with the Medi-Cal fee
schedules, subject to any applicable Medi-Cal program
limitations.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code and Section 12, Assembly Bill 75 (Chapter 1331, Statutes of
1989).
Reference: Section 323.2, and 24165.3(a), Health and Safety
Code.
27 ~
Article 4. Required Services
6840. Required Services.
NOTZ: Authority cited: Sections 208 and 221, Health and Safety
Code. :
Reference: Sections 321.2 (a)~(e), Health and Safety Code.
6842. Outreach and Health Education.
(a) Plan. Each community child health and disability prevention
program shall develop, plan and implement community outreach and
health education activities which are related to the community's
needs and resources. Activities may include, but are not limited
to, community organization, staff training, consultation with
children and families, staff services to community child health
and disability prevention program advisory boards, and the
development and dissemination of informational and educational
material for the public, potential users and providers of the
program's services, advisory board members, local agencies and
community groups.
(b) Outreach. An outreach program shall be as follows:
(1) Community child health and disability prevention programs
shall develop outreach programs to involve persons in the use of
preventive health services. Outreach and health education
services shall be designed to ensure that the only reason
eligible persons do not participate in the health assessment and
referral for diagnosis and treatment portions of the program is
because they intelligently and knowingly decline such
participation for reasons unrelated to availability and
accessibility of the health assessment, diagnosis and treatment
services.
(2) In cooperation with the community child health and
disability prevention program, the governing body of every school
district or private school which has children enrolled in
Kindergarten shall, at the time the parent or guardian registers
a child in kindergarten, inform the parents or guardians as
follows:
(A) It is statutorily required that children provide, within 90
days after entrance into the first grade, either a certificate to
the school documenting that within the prior 18 months the child
has received the appropriate health assessment required by law,
or a waiver signed by the parent or guardian indicating that they
do not want or are unable to obtain such health assessments for
their children.
(B) The health assessment that is required is available from the
child's usual source of health care, the local health department,
some schools and other places in the community.
(C) Rather than wait until the child actually enters first
grade, it is advisable to get the health assessment as early as
possible, preferably within six months prior to kindergarten
entrance, at which time it is also required that the child's
immunizations (a part of the total health assessment) be brought
up to date.
29 BS
(3) The parents or guardians of children entering the firse grade who do not have documentation that the appropriate health assessment has been done or waived shall be informed by the
(A) It is statutorily required that children provide, within 90 days arter entrance into the first grade, either a certificate to the school documenting that within the prior 18 months the child
their children.
(B) The health assessment that is required is available from the child's usual source of health care, the local health department, Some schools and other places in the community.
(c) Informing. Persons eligible to receive CHDP services shall be informed, using effective methods to involve them and in a language understandable to them, about the following:
(1) The value of preventive health services.
(2) Health assessments.
(3) The need for prompt diagnosis and appropriate treatment of Suspected disabilities.
(4) The nature, SCope and benefits of the Ccnild Health and Disability Prevention Program.
(d) Health Education. Health education, including anti-tobacco use education, shall be an integral part of the health assessment.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code and Section 12, Assembly Bill 75 (Chapter 1331, Statutes of 1989). |
Reference: Sections 321.3 (a), 323.5, and 324.2, and 24165.3(c), Health and Safety Code.
38 8
6843. Referral to Dentist.
(a) Availability.
{1) A direct referral to a dentist shall be made for
eligible Medi-Cal beneficiaries three years of age ‘and older
unless dental services have been declined. The dental referral
ls for the purpose of diagnosis and treatment. Dental treatment
consists of dental care needed for relief of pain and infections,
restoration of teeth and maintenance of dental health.
(2) An inspection of the teeth, gums and mouth is part of the
health assessment, and referral to a dentist shall be made if
appropriate.
(b) Informing and training responsibilities. The provisions of
Section 6824 also apply to the information and training
responsibilities of the state and community child health and
disability prevention programs regarding informing Medi-cal
beneficiaries of the availability of dental services, how the
services may be obtained, and of the assistance available with
transportation and scheduling appointments.
(c) Frequency. An annual referral to a dentist for dental
services shall be offered each eligible Medi-Cal recipient three
years of age and older. Dental providers, approved for
participation in the Medi-Cal program, shall be reimbursed for
diagnosis resulting from this annual referral, and for dental
care needed for relief of pain and infections, restoration of
teeth and maintenance of dental health.
{d). Offer of assistance with transportation and scheduling
appointments. Medi-Cal beneficiaries shall be offered assistance
with transportation and scheduling appointments for initial and periodic dental examinations. The response to this offer shall
be recorded, and this assistance shall be provided if requested
by the beneficiary.
(e) Completion of referral. All reasonable steps shall be taken to ensure that Medi-Cal beneficiaries eligible to receive an initial or a periodic dental examination, and who request a referral, complete the referral. An initial dental examination shall normally be completed within 120 days from either the date the beneficiary requests the referral, or the date the beneficiary was certified eligible to receive Medi-Cal benefits, whichever occurs later. A periodic dental examination shall normally be completed within 120 days from either the date the beneficiary requests the referral, or the last day of the month in which the annual dental examination was due, whichever occurs earlier.
(f) Referral sources. The first source of referral for dental services shall be the person's usual source of’ licensed dental care. If no usual source of licensed dental care can be
31 hy,
identified, endo zson shall be given, Bu. prejudice for or against any one source, the names and locations of at least three sources of dental care, when available, which have been approved as providers of dental services by the California Medical Assistance Program. Although the family or recipient may choose to receive dental diagnostic and treatment services from a provider of its choice, to be eligible for state reimbursement, these services shall be provided by Medi-Cal approved providers and in accordance with the provisions of the California Administrative Code, Title 22, Division 3 and subject to any applicable Medi-Cal program limitations.
(g) Documentation. If initial or periodic dental services were not provided to a Medi-Cal beneficiary who had requested such services and who also had requested assistance with transportation or scheduling appointments for services, documentation must exist showing that the family or person lost eligibility, could not be located despite a good faith effort to do so, or the person's failure to receive the services was due to an action or decision by the family or person, rather than a failure by the community child health and disability prevention program to meet requirements of this subchapter, including the requirement to offer and provide assistance with transportation and scheduling appointments for services.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: "Sections. 821.2, 3272.7 and 323.7, Health and Safety Code.
»,
=>
6844. Referral to Health Assessment.
(3) The following shall apply to all persons eligible to receive health assessments under the provisions of this subchapter:
(1) All reasonable steps, including assistance in scheduling and completing appointments if requested, and in following up initial efforts, shall be taken to ensure that persons eligible to receive health assessments, and who request a health assessment, receive it.
(2) Appointments for requested health assessments shall be completed in a reasonable period of time, normally not to exceed 60 days.
(3) The first source of referral for a health assessment shall be the person's usual source of health care. Preference should be given to the comprehensive care provider. If no usual source of health care can be identified, the person shall be given, without prejudice for or against any one provider, the names and locations of at least three providers, when available, who have been approved as providers of health assessments by the community child health and disability prevention program director. The availability of health assessments directly from the clinic operated by the community program may also be made known to the person.
(4) Although a person may choose to receive a health assessment from a provider of the person's choice, to be eligible for state reimbursement, the health assessment shall be provided by providers; who have been approved to bill the Department for these services.
(b) Additional to (a), above, the following shall apply to Medi-Cal beneficiaries who request health assessments:
(1) Medi-Cal beneficiaries shall be offered assistance with transportation and scheduling health assessment appointments. The response to this offer shall be recorded, and this assistance shall be provided if requested by the beneficiary. :
(2) If a person chooses to receive a health assessment from a provider that does not furnish the full range of services as specified in this subchapter, the community child health and disability prevention program shall, if requested, provide or arrange for provision of all such services that are not offered by that provider. At the time of the request, the person must be offered assistance with transportation and scheduling appointments. The response to this offer shall be recorded, and this assistance shall be provided if requested.
(3) If an initial or a periodic health assessment is not provided to a Medi-Cal beneficiary who requests such services and who also requests assistance with transportation or scheduling
3% NN
appointments forvservices, documentation N exist showing that
the family or person lost eligibility, could not be located
despite a good faith effort to do so, or the person's fallure to
receive the services was due to an action or decision by the
family or person, rather than a failure by the community child
health and disability prevention program to meet requirements of
this subchapter, including the requirement to offer and provide
assistance with transportation and scheduling appointments for
services.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code.
Reference: Sections 321.2 (d) and 323.7, Health and Safety Code.
6846. Health Assessment.
(a) Conditions. The following conditions apply to health assessments provided to eligible persons:
{1) A health assessment shall not be provided without the
voluntary consent of the patient.
(2) A health assessment shall not be provided to minors without
the prior and written consent of the minor's parent or guardian
unless one or more of the following circumstances exist:
(A) The minor is emancipated.
(B) The minor is married.
(C) The minor is a member of the military forces.
(D) Provision of the service is exempted from parental consent
by federal or state statute or regulation.
(b) Required screening procedures. Unless medically
contraindicated or deemed inappropriate by the health assessment
provider, or refused by the person, health assessments shall
include the following procedures:
(1) Health and developmental history.
(2) Unclothed physical examination including assessment of
physical growth.
(3) Assessment of nutritional status.
(4) Inspection of ears, nose, mouth, throat, teeth and guns.
(5) Vision screening.
(6) Hearing screening.
(7) Tuberculin testing and laboratory tests appropriate to age and sex, including tests for anemia, diabetes and urinary
tract infections.
(8) i Testing for sickle cell trait and lead poisoning where appropriate. ee
(9) Immunizations appropriate to age and health history necessary to make status current. (Patient shall also receive, subsequent to the health assessment, any immunizations which could not be given during the assessment, and any immunizations
necessary to complete a series which could not be completed during the assessment.) ad,
3s >
(10) Health education and anticipatory guidance appropriate to
age and health status, including anti-tobacco education
guidelines developed or made available by the Department of
Health Services.
(c) Additional screening procedures. A community child health
and disability prevention program may include screening
procedures in its program, additional to the ones included in
this section, if those procedures are approved by the Department
and the State Child Health Board.
(d) Rechecks. In those instances where a person is eligible for
state reimbursement of health assessment costs, reimbursement may
be made for one recheck of those screening procedures (excluding
the Health History and Physical Examination) and laboratory tests
where such a recheck is medically indicated because questionable
or marginal results were obtained during the prior screening.
(e) Results of health assessment. The results of the health
assessment shall be handled as follows:
(1) Health assessment providers shall provide the person with a
copy of the results of the screening tests, with an appropriate
explanation of the results. Such notification and discussion of
screening test results, unless provided by a licensed or
certified practitioner of the healing arts, shall be free of
diagnostic statements or suggestions that the person needs any
particular treatment. Specifically, no medical care or special
education plan shall be instituted solely on the basis of the
health screening results.
(2) Ther.results of the health assessment shall be recorded on
forms provided by the Department.
(f) Concurrent diagnosis and treatment. Nothing in these regu-
lations shall be interpreted to mean that a licensed or certified
practitioner of the healing arts may not provide diagnosis and
treatment, in conjunction with the health assessment, if
medically indicated. :
(g) Nonspecified procedures. Health screening procedures that
are approved for reimbursement by the Department are specified,
together with their maximum allowable reimbursements, in Section
6868. Reimbursement for procedures not specified in Section 6868
shall not be made without written approval of the Department.
NOTE: Authority cited: Sections 208, 321 and 323.7, Health and
Safety Code.
Reference: Sections 321.2 and 324, Health and Safety Code.
6847. Periodicity of Health Assessments.
(a) Eligibility. Medi-Cal beneficiaries who have received an
initial health assessment are also eligible for subsequent,
periodic health assessments.
(b) Notifying and Offering Assistance. Persons eligible for
periodic assessments shall be notified before each assessment is
due of their entitlement to the assessment, and of the
availability of assistance with transportation and scheduling
appointments. The informing may be in writing. The response to
this offer shall be recorded, and this assistance shall be
provided if requested by the beneficiary.
(c) Frequency. Persons eligible for periodic health assessments
shall receive one assessment during each age period listed below.
The first age at which the next health assessment is due is the
age of the person at the previous assessment plus the interval
indicated in the parenthesis after that age period in the table
shown in this subsection. However, a periodic assessment may be
done at any time from the beginning to the end of each age
period. Persons will be considered overdue for an assessment on
the first day he or she enters a new age period without
assessment having been performed in the previous age period. For
example, a child receiving an assessment at two and one-half
years of age is first due for the next assessment at three and
one-half years of age (the age at the time of previous
assessment, two and one-half plus the time interval between
assessments for that age group, one year). The assessment is
overdue when the child is four years old. There is no tine
interval in the 17-20 age period because no additional
assessments will be given after that assessment. Initial and
periodic. assessments, and the initiation of any needed treatment,
shall normally be completed within 120 days from either the last
day the person is eligible for assessment in any age period or
the day the person is notified that the next assessment is due,
whichever occurs first.
The following table is a guide for the minimum frequency at which
health assessments shall be provided to persons eligible for
periodic assessments:
37 Ny
Under 1 month old {1 nonth)
1 through 2 months old {2 months)
J. through 4 months old (2 months)
S through 6 months old (2 months)
7 through 9 months old (3 months)
10 through 12 months old (3 months)
13 through 17 months old (5 months)
18 through 23 months old (6 months)
2 years old (1 year)
3 years old (1 year)
4 through 5 years old (2 years)
6 through 8 years old (3 years)
9 through 12 years old (4 years)
13 through 16 years old (4 years)
17 through 20 years old
(d) Additional Health Assessments. The frequency indicated in
this section is considered a minimum for preventive health
care. More frequent health assessments will be reimbursed when
the additional assessment is deemed appropriate by the health
assessment provider. Circumstances which may indicate the need
for more frequent assessments include the following:
(1) The parents have or the person has a particular need for
education and guidance.
(2) There is the presence or possibility of perinatal disorders
(such as low birth weight, low Apgar scores at birth, prolonged
labor).
(3) The person is or will be exposed to a potentially stressful
environment -- for example, camp or contact sports -- before the
next periodic health assessment indicated by the periodicity
schedule is due.
(e) Limitations. Reimbursement at more frequent intervals will
not be made for a health assessment of an individual for the
purpose of monitoring or treating a specific disease or disorder
previously diagnosed, or for a person whose overall health status
requires ongoing treatment care. Such individuals are still
38 »N
eligible for regular assessments if they are otherwise eligible
for CHDP services.
NOTE: Authority cited: Sections 208, 321 and 323.7, Health and
Safety Code. :
Reference: Sections 320 and 323.7, Health and Safety Code.
6848. Certification for School Entry.
(a) If a child receives a health assessment under provisions of this subchapter, and must present documentation to the school in which the childiis to enroll that the appropriate health Screening procedures specified in Section 6846 have been performed, the physician providing or supervising such sCreening shall give the child or parent or guardian a certificate documenting that the child has received the appropriate health SCreening procedures. The certificate shall be provided whether the cost of the health assessment is reimbursed by the State or paid on behalf of the child.
(b) A child may be certified for school entry by the child's personal physician without receiving a further health assessment 1f the child has received a physical examination and ongoing comprehensive medical care from that physician during the 18 months preceding entry into the first grade, or within 90 days thereafter, and that care has included all the applicable health screening procedures outlined in Section 6846.
(C) The health certification for school entry shall be on forms provided or approved by the Department.
NOTE: Authority cited: Sections 208 and 321 of the Health and Safety Code.
Reference: Section 323.5, Health and Safety Code.
40 ~
6850. Referral to Diagnosis and Treatment.
(a) The following shall apply to all persons for whom diagnosis and treatrnent is indicated as a result of initial or periodic health assessments received under the provisions of this
subchapter:
(1) All reasonable steps, including assistance in scheduling and
completing appointments shall be taken to ensure that persons receive needed diagnosis and treatment services. This referral
assistance shall include giving the family or person the names, address and telephone numbers of providers who have expressed a willingness to furnish, at little or no expense to the family, those treatment services which are not reimbursable by the
Department.
(2) Appointments for diagnostic and treatment services shall be completed in a reasonable period of time, normally not to exceed
60 days from the time of the health assessment.
(3) The health assessment provider shall be responsible for assisting the person in completing diagnosis and treatment. Such
assistance may be rendered directly by the provider or through
the provider's agreements with the community child health and disability prevention program, appropriate agency or individual.
(4) The first source of referral for diagnosis and treatment shall be the person's usual source of licensed Or Certified
health care. If a referral is required and no regular source of licensed or certified health care can be identified, the provider
shall provide a list of at least three appropriate sources of care, when available, without prejudice for or against any specific source or licensed profession. One of the referral sources may be the health assessment provider. State reimbursement for diagnostic and treatment services provided to Medi-Cal beneficiaries can be made only to providers who have been approved for participation in the Medi-cal program.
(5) The community child health and disability prevention program shall:
|
(A) Identify those persons eligible for CHDP services who can obtain needed medical or remedial services through a grantee under Title V of the Social Security Act (Maternal and child Health and Crippled children's Services).
(B) Ensure that persons eligible for Title V services are informed of available services, and referred, if they desire, to Title V grantees that offer services appropriate to the persons’ needs.
41 ™
(6) The source of health care selected by the person shall be indicated on the CHDP assessment form. If that source is other than the assessment provider, a copy of the CHDP referral form or equivalent shall be Provided, with the person's written permission, to the identified source of health care.
(b) Additional to (a), above, the following shall apply to Medi-Cal beneficiaries for whom diagnosis and treatment is indicated as a result of initial or periodic health assessments:
£1) Medi-Cal beneficiaries, who requested assistance with transportation or scheduling the appointment for the health assessment, shall be offered assistance with transportation and scheduling appointments for diagnosis and treatment. The response to this offer shall be recorded, and this assistance shall be provided if requested by the beneficiary.
(2) Medi-Cal beneficiaries, who did not request assistance with transportation or scheduling the appointment for the health assessment, may request assistance with transportation and scheduling appointments for diagnosis and treatment. If the beneficiary requests such assistance, the request shall be documented and the assistance shall be provided.
(3) Treatment needed as a result of an initial health assessment shall normally be initiated within 120 days from either the date the beneficiary requested the health assessment, or the date the beneficiary was certified eligible to receive Medi-Cal benefits, whichever occurs later. Treatment needed as a result of a periodic health assessment shall normally be initiated within 120 days from either the date the beneficiary requested the health assessment, or the last day of the month in which the beneficiary's age exceeds the oldest allowable age for the health assessment according to the periodicity schedule specified in Section 6847, whichever occurs earlier.
(4) If diagnostic and treatment services are not provided to a Medi-Cal beneficiary who requests such services and who also requests assistance with transportation or scheduling appointments for such services, documentation must exist showing that the family or recipient declined the services, lost eligibility, could not be located despite a good faith effort to do so, or the recipient's failure to receive the services was due to an action or decision by the family or recipient, rather than a failure by the community child health and disability prevention program to meet requirements of this subchapter, including the requirement to offer and provide assistance with transportation and scheduling appointments for services.
(c) Each community child health and disability prevention program shall be responsible for developing and maintaining a referral and follow-up system for diagnosis and treatment, and for ensuring that referral is carried out. The referral and follow-up system shall be specified in. the community's child
42 ™
health and disability prevention program plan. Agreements between the community program and providers, and between the community program and other appropriate individuals and agencies participating in the community program, may be part of the referral and follow-up system.
!
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: Sections 321.2, 323.7 and 324, Health and Safety Code.
6852. Diagnosis and Treatment.
(a) To be eligible for state reimbursement, diagnostic and treatment services, which may be required by Medi-Cal beneficiaries as a result of a health assessment received, shall be provided by providers approved for participation in the California Medical Assistance Program. The diagnostic and treatment services shall be in accordance with the provisions of the California Administrative Code, Title 22, Division 3 and subject to any applicable Medi-Cal program limitations.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: Section 323, Health and Safety Code.
PN
4
44 >.
Article 5. Providers of Health Screening and Evaluation Services
6860. Conditions of Participation.
(a) Dental diagnostic and treatment services shall be provided
by or under the supervision of a dentist licensed to practice
dentistry in California. To be eligible for state reimbursement,
billing for dental services shall be in accordance with the
regulations governing the California Medical Assistance Program.
(b) Health assessments shall be performed by or under the
supervision and/or responsibility of a physician licensed to
practice medicine in California. These services shall be
performed in accordance with the provisions of this subchapter.
{C) Each individual, partnership, clinic, group, association,
institution, or public or private agency desiring to participate
in a community child health and disability prevention program as
a provider of health assessments only, or as a provider of
comprehensive health care, shall notify the director of that
program of such intent. Nctification shall be made to the
director of each community child health and disability prevention
program in which it is desired to provide service. Notification
shall be in the manner established by the community program
director.
(4d) Physicians, medical clinics and medical groups may be
approved for participation as providers in the community program
by the community program director on receipt by the director of
written notification stating the following:
(1) The rphysician or medical group understands the requirements
of the Child Health and Disability Prevention Program, and
desires to participate in it as either a comprehensive care
provider or as a provider of health assessments only.
(2) If parts of the required health assessment are not available
in the physician's clinic or group's medical practice, the
physician shall refer the person to other providers approved by
the community program for completion of those parts.
(e) Agencies and organizations (other than physicians and
physician groups) desiring to participate in the community
program, where physicians or other persons under physician supervision will be employed to do parts of the health
assessment, shall state in writing the qualifications of the
screening personnel when notifying the community program director
of their intent to participate as providers. Participation of such agencies and organizations shall require the written
approval of the community program director, and compliance with
the provisions of this subchapter and with any standards that may be established by the community program director.
(f) If the community child health and disability prevention program director- determines that a provider, previously approved
45 ™
for participation in the community program, is not providing
services in accordance with provisions of this subchapter or the
standards established by the community program, the community
program director may withdraw the approval.
(9) Prepaid health plans, thelr subcontractors or
sub-contractors, under contract to the Department to provide
medical care to Medi-Cal enrollees are exempted from the
provisions of this section only for CHDP services that are
provided to their Medi-Cal enrollees. If such a prepaid health
plan wishes to provide CHDP services to persons other than their
Medi-Cal enrollees, full compliance with this section is
required.
(h) Health assessments may be conducted in public and private
school facilities provided that, with respect to private school
facilities, no services provided thereon pursuant to this
subchapter and financed by public funds shall result in any
material benefit to, or be conducted in a manner which furthers
any educational or other mission of, such a school or any person
or entity maintaining the school.
(1) Health assessments shall be made available to eligible
persons as defined in this subchapter without regard to race,
religion, sex, national ‘origin, citizenship, marital status,
parenthood or source of payment.
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code.
Reference: Section 321 (c), Health and Safety Code.
-
6862. Types of Providers.
(2) A health assessment provider shall be a physician, physician
group, or public or private agency or organization that provides
the services specified in this subchapter to persons eligible to
receive those services.
(2) A provider may agree to provide health assessments only, or
nay agree to be a comprehensive care provider, that is, to
provide health assessments and diagnosis and follow-up services.
(c) A health assessment-only provider shall meet the following
conditions unless failure to meet any of them is due to
circumstances other than the provider's inaction:
(1) Assure completion of the full range of health assessment
services appropriate to the individual as defined in Section
6846, including anti-tobacco use education and the completion of
immunizations and immunization series which could not be given
during the health assessment, but which are necessary to make the
immunization status current.
(2) Provide referral for diagnosis and treatment, as specified
ln Section 6850, for all persons identified as needing such
services as a result of health assessments.
(d) A comprehensive care provider shall be certified by
the Department for participation in the California Medical
Assistance program and shall meet the following conditions unless
failure to meet any of them is due to circumstances other than
the provider's inaction:
(1) Assure completion of the full range of health assessment
services appropriate to the person as defined in Section 6846,
including anti-tobacco use education and the completion of immu-
nizations and immunization series which could not be given during
the health assessment, but which are necessary to make the immu-
nization status current.
(2) Initiate diagnosis and treatment, or referral for diagnosis
and treatment, for all persons identified as needing such
services as a result of the health assessment.
(3) Assume overall case management of the person in the event of
subsequent referrals which may be part of the needed diagnosis
and treatment program.
(4) Assure the provision of subsequent, periodic health
assessment at the frequency indicated in Section 6847.
(5) Be available as a source of primary care on a continuing
basis to the person in the event subsequent medical services are
requested. :
(6) Maintain a health record for each person.
~
47 >
NOTE: Authority cited: Sections 208 and 321, Health and Safety
Code and Section 12, Assembly Bil} 75 (Chapter 1331, Statutes of
1989),
Reference: Section 321 (c¢), 323, and 24165.3(c), Health and
Safety Code.
Article 6. Claiming for Services
6866. Procedures.
such services.
as follows:
Insurance carriers shal
exists.
(2) The Department's Child Health and Disability Prevention Program shall be billed, in the manner specified by the program, for health assessments provided to the following persons:
(A) Medi-Cal beneficiaries if those services are reimbursable under (1), above.
(B) Persons who are not Medi-Cal beneficiaries and for whon services are not reimbursable under (1), above, but who meet the age and family income criteria specified by the Department's Child Health and Disability Prevention Program.
Persons enrolled in prepaid health plans that contract with the Depart
1
Department.
(4) Persons may be billed directly for health assessments which are not reimbursable under (1) or (2), above, or the services may be provided at no cost to the person if the provider chooses.
Eligibility for state-subvened health assessments shall be mined by the screening provider prior to the provision of such services.
the Department,
individual or to
(d) Providers' reimbursement claims for health assessments rendered under the provisions of this subchapter shall be subject to audit by the State anytime within three Years beginning with the year in which the claim was filed.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: Section 323.2 (a), Health ang Safety Code.
»
~ 49
6868. Schedule of Maximum Allowances.
gh» (a) Health SCreening Procedures. Reimbursement for tne
Procedures listeq in this subsection, when billed in accordance
with this subchapter, shal} be the amount billed by the provider
for the Procedures Performed, Up to the maximum allowances
Specified in this Subsection. For Purposes of this Subsection:
New patient means a Person who has not Previously received a
health assessment from the examiner, and there is no health
MAXIMUM
HEALTH
SCREENING
PROCEDURE
History and Physical Examination by Comprehensive Care Provider
New Patient or Extended Visit Adolescent
(age 12 through 20 Years)
$49.51
Late childhood
(age 5 through 11 Years)
43.32
Early childhood
(age 1 through 4 years)
40.84
Infant
(age under 1 Year)
38.37
" Routinervisit
Adolescent | (age 12 through 20 Years) ;
39.60
Late childhood (age 5 through 13 Years) |
33.43
|
Early childhoog (age 1 through 4 Years) i
30.95
Infant
(age under 1 year) |
28.46
i By Health Assessment--oOnly Provider New Patient or Extended visit
.
Adolescent
(age 12 through 290 Years) 3 ate childhood
(age 5s through 11 Years) vty childhood (age 1 through 4 Years) fans
: (age under l year)
32.18
:
Routine Visit
Adolescent {age 12 through 20 years)
ss childhood (age 5 through ill years)
gv childhood (age 1 through 4 years)
gail (agg under 1 year)
25.99
Vision Screening
Snellen or equivalent visual acuity test
Age 7 years and older
$2.02
Age 3 through 6 years
4.00
Hearing Screening
Pure Tone Audiometry
S.21
Tuberculin Testing
Multiple Puncture
4.54
Mantoux (intracutaneous)
7.53
(b) laboratory Tests. For laboratory tests listed in this subsection that the provider performs, reimbursement shall be either the provider's usual charge to the general public for the test or the maximum allowance specified in this subsection, whichever is less. If a laboratory test is performed by other than the screening provider, for instance by an outside laboratory, the screening provider may bill the Department's Child Heglth and Disability Prevention Program for the charge made to the provider by the laboratory, Plus a charge not to exceed $4.63 for the provider's collection and handling of the specimen. The total shall not exceed the maximum allowance specified in this subsection for the laboratory test. Clinical laboratory tests shall be performed in the manner and by persons and laboratories that meet the relevant standards established in the Health and Safety Code, the Business and Professions Code and Title 17 of the California Administrative Code. :
MAXIMUM LABORATORY
TEST ALLOWANCE
Blood Tests
Hematocrit
$3.01
Hemoglobin
3.0}
Sickle Cell Status (Electrophoresis) 30.11 *]
Blood Lead Screening :
Free Erythrocyte Protoporphyrin (FEP)
51 a
Blood Lead Level Determination (if FEP Positive) 22.45
7.50
Phenylalanine (PKU) Blood 4.54
Urine Tests
Urinalysis, routine, complete
4.54
Urine "Dipstick"
2.87
Tests for Microorganisms
Culture for Neisseria Gonorrhea
6.02
Cytologic Tests.
Papanicolaou (Pap) Smear
1:22
(c) Immunizations. Reimbursement for the immunizations listed in ‘this subsection, when billed in accordance with this subchapter, shall be the amount billed by the provider for the immunizations given, up to the maximum allowances specified in this subsection. However, if the provider uses vaccine supplied at no cost to the provider by the Department's Immunization Assistance Program, the maximum reimbursement for administration of the vaccine shall be the amount determined by the Department rather than the amount specified in this subsection. The maximum reimbursement rate for the professional component of administering an immunization under this subsection shall be 94.52. The maximum allowable reimbursement for the ingredient component of an immunization shall be based on prevailing market acquisition costs as determined by the Department's fiscal intermediary.
IMMUNIZATION
DPT (diphtheria and tetanus toxoids with pertussis vaccine)
First, second, third of series: booster.
TD (combined tetanus and diphtheria toxoids, adult type) TOPV (trivalent oral polio virus vaccine)
First, second, third of series; booster.
Measles vaccine
Rubella vaccine
Mumps vaccine
MR (measles, rubella) vaccine
MMR (measles, mumps, rubella) vaccine
MuR (mumps, rubella) vaccine
NOTE: Authority cited: Sections 208 and 321, ‘Health and Safety Code, and Sections 14105 and 14124.5, Welfare and Institutions Code. :
Reference: Sections 323 and 323.2 (a), Health and Safety Code; and ;
52 »
Welfare and Institutions Code; Ite Statutes of 1984, and Statutes of 19 1-001 and 890.
Section 14105,
Chapter 258, y Items 4260-11
mS 4260-111-001,
85, Chapter 111,
53 ~N
NOTE: Authority cited: Sections 208 and 321, Code.
Reference: Sections 321.2 {C) and ‘321.2 (h), Health and Safety
Code.
Health and Safety
6872. . Reporting,
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: Sections 320, et seq., Health and Safety Code.
55 NC
(b) The results of the health assessment shall not be released to any public or private agency, even with the consent of the Person or parent or guardian, unless accompanied by a professional interpretation of what the results mean.
NOTE: Authority cited: Sections 208 and 321, Health and Safety Code.
Reference: Section 324.5, Health and Safety Code.
-
A STATEMENT BY THE
CENTERS FOR DISEASE CONTROL
JANUARY 1985
Reprinted July 1985
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL
CENTER FOR ENVIRONMENTAL HEALTH
CHRONIC DISEASES DIVISION
ATLANTA, GEORGIA 30333
©
99-2230
Preface
This second revision of the Centers for Disease Control's (CDC's) statement, Preventing Lead
Poisoning in Young Children, is more comprehensive than the two previous versions. With help
from members of CDC's Ad Hoc Advisory Committee on Childhood Lead Poisoning Prevention
and other expert consultants, we have considered new research findings on lead toxicity, redefined
lead poisoning at a lower blood lead level, and updated our recommendations on lead-based paint
abatement. In addition, a recent article on a new treatment scheme for lead poisoning (symptomat-
ic and asymptomatic) is included.
The precise threshold for the harmful effects of lead on the central nervous system is not
known. In the meantime, we have used our best judgment as to what levels of lead are toxic and
what practical interventions will lower blood lead levels. As public health officials. our duty is to
protect children as best we can—given the limitations of science and the need 10 make decisions
without perfect data. This is the Department of Health and Human Services’ major policy statement
on the issue.
The progressive removal of lead from leaded gasoline is lowering average blood lead levels in
the United States. bul the problem of the major source of high blood lead levels in our
country—millions of old housing units painted with lead-based paint—is largely unsolved. Until
better approaches and more resources are available for removing lead paint hazards in older dwell-
ings where children live, lead poisoning will continue to be a public health problem.
The Committee considered a number of controversial issues, and members vigorously debated
until a majority indicated that they could support the point under consideration. Readers should
carefully weigh the recommendations in this document, and they should pay particular attention to
references to work done since the 1978 CDC statement on lead. This 1985 statement represents
agreement of 11 of the 12 Advisory Committee members. One member, Dr. Jerome F. Cole of the
International Lead Zinc Research Organization, did not support the recommendations. Minutes of
the Advisory Committee meeting on May 17-18, 1984, and Dr. Cole’s statement of dissent are
available upon request.
ACKNOWLEDGMENTS
The time, effort, and meticulous care the Committee devoted to this statement are gratefully ac-
knowledged. This group of dedicated health professionals, along with notable expert consultants.
labored through the results of several years of research in order to gain consensus on extremely
complex issues. The various drafts of this document had the benefit of thoughtful suggestions from
Committee members and consultants alike. Their work will help protect the children of this nation
from this preventable disease for many years to come.
Vernon N. Houk, M.D.
Director
Center for Environmental Health
iii
I. INT ROD UC TION ci lr i it es fsa srr a a i al i I een sata i Sa i 1
DE INIIONIS oe hea eles isn alias ine elusiutin: «nv + "a albino ele nx naa Bt sx win ale x ae ne aan la 1
II. BACKGROUND I. i. svt. i 1 Ca. vrais sit vans sv Baiain ahs win enon in wt a eH ahaha + ol 3
111. SOURCES OER LEAD EXPOSURE cal. a na din id a he var aia ie ay aoa 5
Lead-Baseq Paitll . oi. ses tdie sess tis shes ve in xiv i iy 0 inn wT lee ian an +0 0 4x Sirie wah Vk abere nal ae 5
ADOINE Laat mn. vo hl ies vals seins vn wv ntin on di ee a vy ais 5
TRG BU BR SE BR SE ER TORE CaS NEE ihe OR EN Se aT en EE SE i 7
OCCUPAIONAE SOUTCES i. cull das se rs Std Be iy is Fone rely disin a aly ion Celene Fann oi Wahaein «av a Antes i 1
Food & Drinking Waller. . . cs miss iv svi ss sine vrs Sete «a Fine SR Bh a Rd in 4 aia 7
Lead Glazed PollGIY vo ih i ve ae ey bins oy wie SE pai 1
ih Te Loo non El IRR REE ET IRE So il ek TERN SINR ial 7
IV. SC RE ENING i vt i a i EE aR rae a A 8
Goal Of ChiANOOM Leal PO SO IID a. ce a in nine sini se nie atin oe is vn wet iw a ie wa ay TRG 8
Target POPU ORE. ess sie sae sire sik his en sin rh vn alain ania ain Anan + oo SHoiadeth os din wisluinlncn win ala Ser 8
Screening SChegUE i i ey amy eatin yu an aia i x a ie x hk Rn 8
Screening MelNOMS i er i i i i or ns a i Eh sae rein a aa ha 9
Intervention LeVelS . i. oi on ie id le td a i aie sora a a ew SER a 9
MeasuremeniS OF Erylrocyle PrOtOPOTPIYFIN «or viii sais vin sid sh eve an vn viwn ohn ns Wain sw oho iain 10
Measurement Of BOO LL eat «it sei Ch ys vet on sale sate wiris san Sao arn ne iat ISG 12
Seren SCN, ee clains ss ws sisin viyiabe sis siaivin ae + + awison » aioe at nw aioe So HR kw aan ow bin Aa ain 12
Interpretation Of SCTCENITIE al a shel aia ai aie saw dE aia A we 12
V. DIAGNOSTIC EMAL UA TION cr. is er le eins sinninin asians sda same tna sthiat 14
nL SI TRICE Cl ee NA a CR GE RL al RN MEE SN SEY, £10 NL SOR I 14
VI. CLINICAL MANAGEMENT o.oo Cie dliein w ain minha Dien ta viv eile vin v5 able ie nx sale pr alae 16
UTE RISK i hi, Wiis ove Sins dale vv adie ae wr NI 5s Ten nn ee a A td 16
HES RISK. nn os lee 0's ein edith uh nlnsa i tliiniainsn ae ein + 3 a ale ine When as» www nie wn 0dr Ba A iE 4 17
Lap LE a NE De me EE a Se SR EE REN SI RES fk Pl 17
4 ED pee ple Gl Ee CRER CTUER BR Re SS ae re SI ES Lg Gr EER oe of 17
VII. ENVIRONMENTAL EVALUATION AND LEAD HAZARD ABATEMENT ...................... 18
Lead-Based Pall. «cia Bi ei sinie vite sii 5 iain an Sis wna ins $n aN in a dee ee hike a he ee ade 18
ot in nr BN SIRES SRR Sal TR RL ee Me PE i SE CES En ol or TE le 20
COE Bo RE SE SR TR RN RR. CE SL CO Cae LR SN Se Sc WE REI Oe 20
FOO & WEL 7s i te te ie cs tira tloisie sins s ns oie lit nn Mh wats ie aa win 5 ine wx wn nea i aL 20
OC CHD A ON Al a se cieiins viv iso vinis is epermiais se ona ie sv win oivie ie + +x v 5 + KARA AY Fon A ARE nr aa 20
Lead- Glazed POlOTY iv. ss ie sires + 5 syskotete, slats = six siviite:viainls auiein Haluivi «me anim on ns v vw aphve x 44% ss 21
VII. HEALTHEDUCATION cf. cscs icie cris «nolo non csinie sity nie sate stein sn sinn eons sin sinuses saomoninaiess 2
IX. REPORTING LEAD TOXICITY AND ELEVATED BLOOD LEAD LEVELS ..................... 22
X. PEER ER ENCES oe «ci cieicis retires ove rain inn 8 vin abe vie HT aan a ns ae it «aa Eon sii ame 23
APPENDIX — Management of Childhood Lead Poisoning: Special Article ................................ 26
I. Introduction
Lead is ubiquitous in the human environment as a
result of industrialization. It has no known physiologic
value. Excessive absorption of lead is one of the most
prevalent and preventable childhood health problems in
the United States today. Children are particularly sus-
ceptible to its toxic effect.
Since 1970, the detection and management of children
exposed to lead has changed substantially. Before the
mid-1960’s, a level below 60 micrograms of lead per
deciliter (ug/dl) of whole blood was not considered
dangerous enough to require intervention (Chisolm,
1967). By 1975, the intervention level had declined
50% —10 30 wg/dl (CDC, 1975). In that year, the Center
(now Centers) for Disease Control (CDC) published /n-
creased Lead Absorption and Lead Poisoning in Young
Children: A Statement by the Cenier for Disease Control.
Since then, new epidemiologic, clinical, and experimental
evidence has indicated that lead is toxic at levels pre-
viously thought to be nontoxic. Furthermore, it is now
generally recognized that lead toxicity is a widespread
problem —one that is neither unique to inner city children
nor limited to one area of the country.
Progress has been made. The Second National Health
and Nutrition Examination Survey (NHANES II) has es-
tablished average blood lead levels for the U.S. popula-
tion; lead-contaminated soil and dust have emerged as
important contributors to blood lead levels, as has leaded
gasoline, through its contribution to soil and dust lead
levels. An increasing body of data supports the view that
lead, even at levels previously thought to be “safe.” is
toxic to the developing central nervous system; and
screening programs have shown the extent of lead poison-
ing in target populations.
A major advance in primary prevention is the phased
reduction of lead in gasoline. It is probably responsible
for the findings of reduced average blood lead levels in
children nationwide (Annest et al., 1983) and in two
major cities (Rabinowitz and Needleman, 1982; Billick et
al., 1980; Kaul et al., 1983). Lead is no longer allowed in
paint to be applied to residential dwellings, furniture, and
LOysS.
The sources of lead are many. They include air, water,
and food. Despite the 1977 ruling by the Consumer Pro-
duct Safety Commission (CPSC) that limits the lead con-
tent of newly applied residential paints, millions of hous-
ing units still contain previously applied leaded paints.
Older houses that are dilapidated or that are being
renovated are a particular danger to children. In many
urban areas, lead is found in soil (Mielke et al., 1983) and
house dust (Charney et al., 1983). Consequently, screen-
ing programs—a form of secondary prevention —are still
needed to minimize the chance of lead poisoning devel-
oping among susceptible young children.
Lead poisoning challenges clinicians, public health au-
thorities. and regulatory agencies to put into action the
findings from laboratory and field studies that define the
risk for this preventable disease. Although screening pro-
grams have been limited, they have reduced the number
of children with severe lead-related encephaiopathy and
other forms of lead poisoning.
The revised recommendations in this 1985 Statement
reflect current knowledge concerning screening, diagno-
sis, treatment, followup, and environmental intervention
for children with elevated blood lead levels. Clearly, the
goal is to remove lead from the environment of children
before it enters their bodies. Until this goal is reached,
screening, diagnosis, treatment, followup, and secondary
environmental management will continue to be essential
public health activities.
DEFINITIONS
The two terms defined below—elevated blood lead
level and lead toxicity —are for use in classifying children
(whose blood has been tested in screening programs) for
followup and treatment. The terms should not be inter-
preted as implying that a safe level of blood lead has been
established. Furthermore, they are to be used as guide-
lines. They may not be precisely applicable in every case.
Each child needs to be evaluated on an individual basis.
The CDC is lowering its definition of an elevated
blood lead level from 30 to 25 wg/dl. The definitions
below are simplified versions of those in Preventing Lead
Poisoning in Young Children: A Statement by the Center for
Disease Control: April 1978 (CDC. 1978).
® elevated blood lead level, which reflects excessive
absorption of lead, is a confirmed concentration of
lead in whole blood of 25 ug/dl or greater;
II. Background
A nationwide survey, conducted from 1976-1980,
showed that children from all geographic areas and socio-
economic groups are at risk of lead poisoning (Mahaffey,
Annest et al., 1982). Data from that survey indicate that
3.9% of all U.S. children under the age of 5 years had
blood lead levels of 30 ug/dl or more. Extrapolating this
to the entire population of children in the United States
indicates that an estimated 675,000 children 6 months to
5 years of age had blood lead levels of 30 wug/dl or more.
There was, in addition, a marked racial difference in
those data. Two percent of white children had elevated
blood lead levels, but 12.2% of black children had elevat-
ed levels. Further, among black children living in the
cores of large cities and in families with annual incomes
of less than $6,000, the prevalence of levels of 30 ug/dl
or more was 18.6%. Among white children in lower
income families, the prevalence of elevated lead levels
was eight times that of families with higher incomes.
In the past decade, our knowledge of lead toxicity has
greatly increased. Previously, medical attention focused
on the effects of severe exposure and resultant high body
burdens associated with clinically recognizable signs and
symptoms of toxicity (Perlstein and Attala, 1966; Chi-
solm, 1968; Byers and Lord, 1943). It is now apparent
that lower levels of exposure may cause serious behavior-
al and biochemical changes (De la Burde and Choate,
1972, 1975; NAS, 1976; WHO, 1977). Recent studies
have documented lead-associated reductions in the bio-
synthesis of heme (Piomelli et al., 1982), in concentra-
tions of 1,25-dihydroxy vitamin D (Rosen et al., 1980;
Mahaffey, Rosen et al., 1982), and in the metabolism of
erythrocyte pyrimidine (Angle and McIntire, 1978:
Paglia et al., 1977). Results of a growing number of stud-
ies indicate that chronic exposure to low levels of lead is
associated with altered neurophysiological performance
and that the young child is particularly vulnerable to this
effect (Needleman et al., 1979; Winneke, 1982; Yule et
al., 1981). Investigations have also shown alterations in
electroencephalograms (EEG’s) (Burchfiel et al., 1980;
Benignus et al., 1981; Otto et al., 1982) and decreased
velocity in nerve conduction (Seppalainen and Hernberg,
1982; Feldman et al., 1977).
Many factors can affect the absorption, distribution,
and toxicity of lead. Children are more exposed to lead
than older groups because their normal hand-to-mouth
activities introduce many nonfood items into their bodies
(Lin-Fu, 1973). Once absorbed, lead is distributed
throughout soft tissue and bone. Blood levels reflect the
dynamic equilibration between absorption, excretion,
and deposition in soft- and hard-tissue compartments
(Rabinowitz et al., 1976). Young children absorb and
retain more lead on a unit-mass basis than adults. Their
bodies also handle lead differently. Higher mineral turn-
over in bone means that more lead is available to sensitive
systems. The child’s nutritional status is also significant
in determining risks. Deficiencies in iron, calcium, and
phosphorus are directly correlated with increased blood
lead levels in humans and experimental animals (Mahaf-
fey, 1981; Mahaffey and Michaelson. 1980). Increased
dietary fat and decreased dietary intake of calcium
(Barltrop and Khoo, 1975: Rosen et al., 1980), iron
(Mahaffey-Six and Goyer, 1972), and possibly other nu-
trients enhance the absorption of lead from the intestine
(NAS, 1976; Barltrop and Khoo, 1975).
Since lead accumulates in the body and is only slowly
removed, repeated exposures to small amounts over
many months may produce elevated blood lead levels.
Lead toxicity is mainly evident in the red blood cells
and their precursors, the central and peripheral nervous
systems, and the kidneys. Lead also has adverse effects
on reproduction in both males and females (Lane. 1949).
New data (Needleman et al., 1984) suggest that prenatal
exposure to low levels of lead may be related to minor
congenital abnormalities. In animals, lead has caused
tumors of the kidney. The margin of safety for lead is
very small compared with other chemical agents (Royal
Commission on Environmental Pollution, 1983).
The heme biosynthetic pathway is one of the biochemi-
cal systems most sensitive to lead. An elevated EP level
is one of the earliest and most reliable signs of impaired
function due to lead. A problem in determining lead
levels in blood specimens is that the specimen may be
contaminated with lead, and thus the levels obtained may
be falsely high. Therefore, in the initial screening of
asymptomatic children, the EP level (instead of the lead
level) is determined.
The effects .of lead toxicity are nonspecific and not
readily identifiable. Parents, teachers, and clinicians may
identify the altered behaviors as attention disorders,
learning disabilities, or emotional disturbances. Because
I11. Sources of Lead Exposure
Children may be exposed to lead from a wide variety
of man-made sources. All U.S. children are exposed to
lead in the air, in dust, and in the normal diet (Figure 1).
Airborne lead comes from both mobile and stationary
sources. Lead in water can come from piping and distribu-
tion systems. Lead in food can come from airborne lead
deposited on crops, from contact with “leaded” dust
during processing and packaging, and from lead leaching
from the seams of lead-soldered cans. In addition to expo-
sure from these sources, some children, as a result of
their typical, normal behavior, can receive high doses of
lead through accidental or deliberate mouthing or swal-
lowing of nonfood items. Examples include paint chips,
contaminated soil and dust, and, less commonly, solder,
curtain weights, bullets, and other items.
LEAD-BASED PAINT
Lead-based paint continues to be the major source of
high-dose lead exposure and symptomatic lead poisoning
for children in the United States (Chisolm, 1971). Since
1977, household paint must, by regulation, contain no
more than 0.06% (600 parts per million (ppm)) lead by
dry weight. In the past, some interior paints contained
more than 50% (500,000 ppm) lead. The interior surfaces
of about 27 million households in this country are con-
taminated by lead paint produced before the amount of
lead in residential paint was controlled. Painted exterior
surfaces are also a source of lead. Unfortunately, lead-
based paint that is still available for industrial, military,
and marine usage occasionally ends up being used in
homes.
Usually, overt lead poisoning occurs in children under
6 years of age who live in deteriorated housing built
before World War Il. Pica, the repeated ingestion of non-
food substances, has frequently been implicated in the
etiology of lead toxicity in young children. In many cases,
however, lead-paint ingestion is simply the result of the
normal mouthing behavior of small children who live in
lead-contaminated homes. Cases of children poisoned by
lead paint have been reported from all regions of the
United States and from both urban and rural settings. In-
creasingly, this poisoning has been reported when fami-
lies move into a cily as “urban homesteaders.” and the
children are inadvertently exposed to chips, fumes, or
dust from lead-based paint as houses are rehabilitated.
Clusters of lead-based paint poisonings have also resulted
from demographic shifts within cities, when families with
young children have moved into neighborhoods with
deteriorating older housing. Increased lead absorption
has been reported in children exposed to chips or dust
from lead-based paint produced during the deleading of
exterior painted steel structures, such as bridges and ex-
pressways (Landrigan et al., 1982).
AIRBORNE LEAD
Generally, inhalation of airborne lead is a minor expo-
sure pathway for individual children, but lead-containing
particles— airborne and then deposited —can be responsi-
ble for high concentrations of lead in dust that children
ingest. Studies in New Jersey (Caprio et al., 1974) and
California (Johnson et al., 1975) have shown that chil-
dren living within 100 feet of major roadways have higher
blood lead levels than those living farther away. These
levels also correlate positively with the average daily traf-
fic volume on roads near homes (Caprio et al., 1974).
Previous estimates of the quantitative relationship be-
tween ambient air lead levels and blood lead levels may
need to be revised because of new experimental and
survey data. Preliminary results from an isotopic lead ex-
periment (Facchetti and Geiss, 1982) suggest that lead
from leaded gasoline is a much more important contami-
nant than it was previously thought to be. The preliminary
estimates from that study indicate that at least 25% of the
blood lead of residents of Turin, lialy, is derived from
lead in gasoline. In Turin, the average blood lead level in
adult males is 25 ug/dl; this corresponds to about 6 ug/dl
attributable to gasoline.
Data from NHANES II also indicate that leaded gaso-
line is a more significant source of lead than previously
thought. Annest et al. (1983) correlated major reductions
in the amounts of lead added to gasoline sold in the
United States with significant reductions in children’s
blood lead levels. They found that between 1976 and
1980, the overall mean blood lead levels in the U.S. popu-
lation dropped from 14.6 ug/dl to 9.2 ug/dl. A similar
relationship between leaded gasoline sales and umbilical
cord blood lead levels has been shown by Rabinowitz and
Needleman (1983).
Stationary sources can produce concentrated zones of
exposure, especially where climatic conditions such as
aridity, low wind velocity, and frequent thermal inver-
sions minimize dispersal of airborne lead. The worst situ-
ations of this kind in the United States have existed in the
vicinity of primary lead smelters (Baker, Hayes et al.,
1977).
SOIL AND DUST
Soil and dust that contain lead are often an important
source of lead exposure for children. The particles of air-
borne lead deposited in soil and dust usually come from
automotive, industrial, and similar sources. Flaking lead
paint adds to this contamination, particularly in and
around houses. In soil, lead tends to remain in the top
centimeter, bul most soils are contaminated to a much
greater depth when the topsoil is disturbed and turned
under.
Children appear to obtain lead from dust and soil as a
result of their normal exploratory behavior (Barltrop,
1966; Sayre et al., 1974; Roels et al., 1976), coupled in
some instances with pica. Because of those mouthing
tendencies, young children who live near major sources
of airborne lead pollution must be considered at risk of
exposure both by inhalation of airborne lead and by inges-
tion of deposited lead from soil and dust.
In general, lead in soil and dust appears to be responsi-
ble for blood lead levels in children increasing above
background levels when the concentration in the soil or
dust exceeds 500-1,000 ppm.
OCCUPATIONAL SOURCES
Lead dust can cling to the skin, hair, shoes, clothing,
and vehicles of workers, and lead can be carried from
workplace to home in this way. In a study in Memphis,
Tennessee, when a parent worked with lead, the amount
of lead in the children’s blood correlated with the concen-
tration of lead in dust in their homes (Baker, Folland et
al., 1977). Of 91 children tested, 38 (41.8%) had blood
lead levels of 30 ug/dl or more, and 10 either had blood
lead levels of 80 ug/dl or more or EP levels above 190
mg/dl.
Strict compliance with Occupational Safety and Health
Administration (OSHA) standards is quite effective in
decreasing this type of exposure. However, many occupa-
tional exposures to lead are not covered by the OSHA
standards. Companies with fewer than 10 employees (cot-
tage industries, “hobby” production of pottery and
stained glasswork, and home manufacturing of bullets
and fishing sinkers) are excluded from OSH A standards.
The OSHA standard for lead workers is a blood lead
level of 40 wg/dl. In a pregnant woman, lead crosses the
placenta, and lead concentrations in umbilical cord blood
are nearly equal to those in maternal blood (Barltrop,
1966). Since the growing brain of the fetus is likely to be
al least as sensitive Lo the neurologic effects of lead as the
brain of a young child, umbilical cord blood levels should
be al least below 25 ug/dl. Therefore. the OSHA standard
is probably not sufficiently strict to protect the fetus. Fur-
ther study is needed to define acceptable lead levels
among women of childbearing age.
FOOD AND DRINKING WATER
Lead in food. although rarely responsible for lead
poisoning in the United States, is a ubiquitous source of
background low-dose exposure for children (Beloian,
1982). Agricultural crops grown near heavily traveled
roads or near stationary sources of lead can have signifi-
canl concentrations because of airborne lead deposited
on them. Lead may also be inadvertently added to foods
during processing and handling. Canned foods may have
particularly high lead contents, because acidic foods can
leach lead from the solder in the seams of the cans
(Lamm etal., 1973).
Generally, lead in drinking water has been leached
from pipes and soldered joints by soft water having an
acidic pH. Severe lead exposure has been reported among
children in Glasgow, Scotland, where pure, acidic water
was allowed to stand overnight in attic cisterns lined with
lead (Beattie et al., 1972). The problem was alleviated by
changing the pH of the water in the walter treatment
plant. In the United States, lead water pipes are most
commonly found in older sections of northeastern cities
and, occasionally, in rural areas of the northeast (Morse
etal., 1979).
LEAD-GLAZED POTTERY
Although not a widespread source of lead, lead-glazed
potlery can release large amounts of lead into food and
drink. It has been responsible for outbreaks of serious
poisoning (Klein et al., 1970). In several episodes report-
ed to CDC, the pottery had been imported. Homemade
or craft pottery and porcelain-glazed vessels have been
found to release large quantities of lead, particularly if the
glaze is chipped, cracked, or improperly applied (Osterud
et al., 1973). If the vessels are repeatedly washed, the
glaze may deteriorate and potlery previously tested as
safe can become unsafe (D. M. Wallace, personal
communication).
OTHER SOURCES
Lead is found in a variety of items, some of which
endanger specific populations or ethnic groups. A variety
of folk remedies contain lead, including azarcon and greta
used by Mexican groups and pay-loo-ah used by Hmong
refugees from Laos. Serious poisoning can also result
from gasoline sniffing; the burning of waste oil, colored
newsprint, battery casings, or lead-painted wood; and
target practice in poorly ventilated, indoor firing ranges.
SCREENING METHODS
Currently, the most useful screening tests are those
for erythrocyte protoporphyrin (EP) and blood lead.
Venous or capillary blood can be used for both tests, but
capillary specimens are easier to collect and are, there-
fore. more widely used. Capillary blood may be transport-
ed in a capillary tube with an anticoagulant or dried on
filter paper. Sampling methods used in the field must be
compatible with laboratory capabilities.
EP and blood lead tests measure different aspects of
lead toxicity. As stated earlier, EP tests measure the level
of EP in whole blood, and a level of 35 ug/dl or more indi-
cates impaired heme synthesis, which may be due to the
toxic effects of lead; blood lead tests measure lead absorp-
tion, and a confirmed concentration of 25 g/dl or more,
referred to as an elevated blood lead level, reflects an ex-
cessive absorption of lead. Usually, there is a close corre-
lation between results of the two tests for specimens from
the same child, but, occasionally, the result of one test
may be elevated and the result of the other, not elevated.
The EP test has three advantages over the blood lead test:
(1) when blood lead levels are moderately elevated, the
EP test better identifies children with rising blood lead
levels (Reigart and Whitlock, 1976); (2) if the specimen
is contaminated with lead, the contamination does not
affect the EP test; and (3) the EP test is an accepted
screening test for iron deficiency.
INTERVENTION LEVELS
Children screened for lead poisoning can be grouped
into two categories: those who require further evaluation
and those who do not. Choosing the intervention level
that divides these two groups is based on a compromise
among the following:
(1) the desire to identify all children with any degree
of lead toxicity
(2) a judgment about the urgency of preventing vari-
ous detectable effects
(3) the sensitivity and specificity of a practical screen-
ing test
(4) society’s ability to remove the sources of lead
exposure
A. Pathophysiological Considerations
In recent years, levels of exposure previously consid-
ered “safe” have been shown to produce adverse effects.
In addition, contemporary people (including children)
living in remote areas with negligible exposure to lead
have blood lead levels much lower than people living in
the United States (Piomelli, 1980). Thus, the blood lead
levels of U.S. children reflect a high degree of environ-
mental contamination by lead. Today, the average blood
lead level in the U.S. population is about 10
ng/dl—approximately three times the average level
found in some remote populations. These observations
suggest that the average level in the U.S.A. should be re-
duced. At present, however, because of practical consid-
»
erations, the goal of reducing U.S. levels to those of
remote populations is unattainable. Therefore. the blood
lead level at which intervening action should be taken
should be based on (1) criteria that indicate significant
risk to the individual child and (2) the best combination
of tests: a test for the blood lead level as an indicator of ab-
sorption and a test for EP as an indicator of biochemical
derangement.
Since the CDC's 1978 statement on lead poisoning,
several investigators have demonstrated effects of low-
level lead exposures in these areas:
1. children’s behavior and intelligence (Needleman et
al., 1979; Winneke, 1982; Yule et al.. 1981)
. the central and peripheral nervous systems of adult
workers (Mantere et al.,, 1982; Seppalainen and
Hernberg, 1982)
3. heme biosynthesis in children (Piomelli et al., 1982)
4. nucleotide metabolism (Angle and McIntire, 1978)
5. vitamin D metabolism in children (Rosen et al..
1980; Mahaffey, Rosen et al., 1982).
The precise level at which lead exposure begins to
cause developmental or neurobehavioral problems in
children may be impossible to define in the near future.
In the meantime, decisions on public health measures
have to be made on the basis of (1) other, more objective-
ly measurable effects and (2) an adequate margin of
safety.
The elevation of EP, a toxic effect of lead in humans,
has been well studied and it can be measured objectively.
Among the biologic markers of lead toxicity, EP measure-
ments have been the most useful in screening programs
for lead poisoning. Recent studies have shed new light on
the effects of lead and of iron deficiency on EP levels.
Several years ago, Roels et al. (1976), basing their
argument on EP measurements, stated that a blood lead
level of 25 ug/dl should be the maximum permissible
concentration. Cavalleri et al. (1981), who made a study
around a lead smelter, indicated that even this level may
be too high. This group found an EP response at blood
lead levels ranging between 10 and 20 ug/dl, suggesting
that the EP no-response level is lower than 10 ug/dl. In a
more recent and comprehensive examination of the
issue, Piomelli et al. (1982) studied data from over 2.000
children. Blood lead and EP tests were done on venous
specimens collected from children throughout New York
City. Piomelli and his colleagues were trying to find the
blood lead level at which the EP level began to increase.
A variety of statistical techniques were used, and the find-
ings were consistent; when blood lead levels increased
linearly above the area of 15-18 ug/dl, the EP level in-
creased exponentially.
Recent studies of EDTA (calcium disodium ethylene
diamine tetraacetic acid) mobilization testing indicate
that the amount of lead excreted by children with blood
lead levels of 30-40 wg/dl may often be comparable to
that excreted by children with levels of 50-70 ug/dl (Mar-
kowitz and Rosen, 1984). This finding suggests that the
0)
hee
For both the hematofluorometer and the extraction
method, the distinction between a positive and negative
screening test should be based on a cutoff level of 35
wng/dl. However, for risk classification, the cutoff points
for ZnPP measured by hematofluorometer (Table 2.A)
differ from those for EP measured by the extraction
method (Table 2.B). If possible, centralized laboratories
should use extraction methods, and, if the followup
laboratory has extraction capability, all confirmatory tests
for EP should be done by extraction, not hematofluo-
rometer. Hematofluorometers are most likely to give
accurate results when used to analyze freshly collected
blood specimens. The differences between methods need
further study.
B. Erythrocyte Protoporphyrin and Iron Deficiency
A benefit of EP screening is that when an elevated EP
level proves not to be due to lead, it usually reflects iron
deficiency (Piomelli, 1977). The first signs of iron defi-
ciency are biochemical abnormalities (low serum ferritin,
low transferrin saturation, and high EP) followed by cel-
lular abnormalities (microcytosis and hypochromia).
Iron deficiency anemia follows these changes as the
hemoglobin and hematocrit values fall.
The EP test proved to be practical in screening for iron
deficiency in a population of 4,160 children (Yip et al.,
1983). The upper limit of normal for EP in this study was
35 ng/dl. The predictive value appeared to be satisfactory.
Iron deficiency is common in many of the groups at
risk for lead poisoning—especially among inner-city
children of low socioeconomic status living in old, dilap-
idated housing. Iron deficiency is common among infants
ages 9 to 24 months; the highest frequency of lead poison-
ing extends through 36 months. Iron deficiency and lead
toxicity may occur in the same child. Furthermore, ex-
perimental evidence indicates that iron deficiency in-
creases the proportion of lead absorbed from the intestine
and aggravates the toxic effects of lead.
Analysis of the NHANES II data has clarified the rela-
tionship between elevated EP values, blood lead levels,
and iron deficiency in a representative sample of the U.S.
population. Among children in the NHANES II survey
with elevated EP values, 31% have elevated blood lead
levels, 18% have iron deficiency (as evidenced by a trans-
ferrin saturation of less than or equal to 12%), and 11%
have evidence of both conditions (R. Yip, personal com-
munication). On the other hand, among children with
elevated blood lead levels, only about 26% have lead
toxicity—that is, an elevated EP level (NCHS, 1984). In
high priority populations (Table 1), in which iron defi-
ciency is more common and lead levels are higher, a
greater proportion of children with elevated blood lead
levels would have elevated EP levels. Analyses by both
Yip and NCHS confirm that a synergistic effect exists be-
tween lead toxicity and iron deficiency in children, as ex-
perimental studies in animals have suggested.
11
Table 2.A
Zinc Protoporphyrin (ZnPP) by Hematofluorometer
Risk Classification of Asymptomatic Children
for Priority Medical Evaluation
Erythrocyte Protoporphyrin (EP) #
Blood Lead #
<35 35-74 75-174 >178
Not done I - : .
<24 | la la EPP +
25-49 Ib 11 11 11
50-69 * Il Il Iv
> 70 Bw ae Vv 1v
# Units are in ug/dl of whole blood.
Blood lead test needed to estimate risk.
Erythropoietic protoporphyria. Iron deficiency may cause
elevated EP levels up to 300 ug/dl, but this is rare.
In practice, this combination of results is not generally ob-
served; if it is observed, immediately retest with whole blood.
NOTE: Diagnostic evaluation is more urgent than the classification indi-
cates for—
Children with any symptoms compatible with lead toxicity.
Children under 36 months of age.
Children whose blood lead and EP levels place them in the
upper part of a particular class.
4. Children whose siblings are in a higher class.
w
h
a
These guidelines refer to the interpretation of screening results, but the
final diagnosis and disposition rest on a more complete medical and
laboratory examination of the child.
Table 2.B
Erythrocyte Protoporphyrin (EP) by Extraction
Risk Classification of Asymptomatic Children
for Priority Medical Evaluation
Erythrocyte Protoporphyrin (EP) #
Blood Lead #
<35 35-109 110-249 > 250
Not done I ad : :
<24 I Ia la EPP+
25-49 Ib I 11 11
50-69 *" HI HI v
>70 in i Iv Iv
# Units are in ug/dl of whole blood.
*
w
n
Blood lead test needed to estimate risk.
Erythropoietic protoporphyria. Iron deficiency may cause
elevated EP levels up to 300 ug/dl, but this is rare.
In practice, this combination of results is not generally ob-
served; if it is observed, immediately retest with venous
blood.
NOTE: Diagnostic evaluation is more urgent than the classification indi-
cates for—
1. Children with any symptoms compatible with lead toxicity.
2. Children under 36 months of age.
3. Children whose blood lead and EP levels place them in the
upper part of a particular class.
4. Children whose siblings are in a higher class.
These guidelines refer to the interpretation of screening results, but the
final diagnosis and disposition rest on a more complete medical and
laboratory examination of the child.
and in no case later than within 48 hours. Children in
class III are at high risk. Those in class II are at moderate
risk, and those in class I, at low risk.
Class I can be subdivided into two additional catego-
ries. Class la (blood lead, 25 ug/dl or less, and EP, 35
ug/dl or more) includes children with iron deficiency.
These children should be retested, with additional assess-
ment of iron status. Class Ib (blood lead, 25-40 ug/dl,
and EP, less than 35 ug/dl) covers children who appear
to have transient, stable, declining, or increasing blood
13
lead levels. Results should be confirmed by retesting, and
the children should be carefully followed. In some cases,
the blood lead and EP results will differ. When the EP
value is significantly higher than the value suggested by
the blood lead level, the child probably has both iron defi-
ciency and excessive lead absorption.
Screening should focus on asymptomatic children.
Children with symptoms should be referred for immedi-
ate evaluation, regardless of their risk classification.
1. Tests for Iron Deficiency
Because the EP can reflect iron deficiency as well as
lead exposure, the presence of iron deficiency must be es-
tablished or ruled out if EP levels are to be properly
interpreted.
A common misconception is that a child with a
“normal” hematocrit (33% or more) or hemoglobin con-
centration (11 g/dl or more) could nor be iron deficient.
This is not true, particularly with respect to iron deficien-
cy sufficient to affect EP and, worse, to enhance lead ab-
sorption and retention. Thus, although a complete blood
count (CBC) and a reticulocyte count are indicated in the
evaluation of lead toxicity, they are not sensitive enough
to rule out iron deficiency.
Of the red blood cell (RBC) indices, a decreased mean
corpuscular volume (MCV) is a useful indicator of iron
deficiency. Normal values depend on age (Dallman,
1982).
Serum iron and iron binding capacity are more sensi-
tive than the MCV. In general, an elevated iron binding
capacity of more than 350 ug/dl is more likely to accurate-
ly indicate iron deficiency than a normal or low serum
iron, since the serum iron is quite sensitive to both di-
etary iron and diurnal variation. Thus, if a child has eaten
an iron-rich food within 2-4 hours before the blood for
the test is drawn, the result may be closer to the normal
level than is actually the case. Under standardized condi-
tions, an abnormally low ratio of serum iron to iron bind-
ing capacity (transferrin saturation) is consistent with
iron deficiency. In addition to the level of EP itself, the
serum ferritin level is an accurate indication of overall
iron status.
2. Flat Plate of the Abdomen
Radiologic examination (flat plate) of the abdomen
may reveal radiopaque foreign material, but only if the
material has been ingested during the preceding 24 to 36
hours. Since lead ingestion is sporadic, this examination
is significant only if the results are positive; negative re-
sults do nor rule out lead poisoning. Positive results indi-
cate recent ingestion of large amounts of lead.
3. X-ray of Long Bones
X-rays of the long bones, usually the knees, may help
estimate the duration of exposure. Lines of increased
density in the metaphyseal plate of the distal femur and
proximal tibia and fibula are “growth arrest lines.” They
are caused by lead, which disrupts the metabolism of the
bone matrix. As a result, areas of increased mineraliza-
tion or calcification may be present at the metaphyses of
the long bones. Though sometimes called “lead lines,”
they are not an x-ray shadow of deposited lead.
Although definitive data are not available, these lines
are thought to become visible after at least 4 to 8 weeks
from the time exposure began; the length of time
depends on the age of the child and the degree of lead
exposure. The width and intensity of the lines reflect pro-
longed previous lead absorption but do not indicate cur-
rent ingestion. They are seldom seen in children under
24 months of age. Negative x-rays do not rule out lead
poisoning.
. Calcium Disodium EDTA Mobilization (or Provoca-
tive Test)
This test is used to identify children who will respond
to chelation therapy with a brisk lead diuresis. Children
whose blood lead level exceeds 55 ug/dl should not re-
ceive a provocative chelation test. Instead, appropriate
chelation therapy should be started. The mobilization test
is particularly useful when the screening test indicates
that the child has lead toxicity and there is some question
as to whether chelation therapy is indicated. This test pro-
vides an index of the mobile or potentially toxic fraction
of the total body lead burden (Saenger et al., 1982).
Since CDC’s 1978 statement, an 8-hour mobilization
test has been shown to be as reliable as a 24-hour mobili-
zation test (Markowitz and Rosen, 1984). Although an
8-hour test may be done on an outpatient basis, the pa-
tient should not leave the clinic. The careful use of “lead-
free” apparatus is mandatory.*
. Lumbar Puncture
CAUTION:
If a lumbar puncture is needed to rule out meningitis
or other serious disease, it should be performed cau-
tiously and only after a careful search for signs and
symptoms of increased intracranial pressure. The fluid
should be obtained drop by drop, and no more than 1
milliliter (ml) should be removed.
The following tests are not useful in diagnosing lead
toxicity.
1. Microscopic Examination of Red Cells for Basophilic
Stippling
Since basophilic stippling is not universally found in
chronic clinical lead poisoning and is relatively insensitive
to lesser degrees of lead toxicity, it is not considered
useful in diagnosis.
2. Tests of Hair and Fingernails for Lead Levels
The levels of lead in hair or fingernails are not well cor-
related with blood lead levels; therefore, tests for these
levels are nor considered useful in diagnosis.
*Special lead-free collection apparatus must be used if valid test results
are to be obtained. The laboratory performing the analysis may supply
the proper collection apparatus. Preferably, urine should be voided
directly into polyethylene or polypropylene bottles that have been
cleaned by the usual procedures, then washed in 1% nitric acid, and
thoroughly rinsed with deionized, distilled water. For children who are
not toilet trained, plastic pediatric urine collectors, with double com-
partments, may be used. Urine collected in this manner should be
transferred directly to the urine collection bottles. Preserving the col-
lected urine with hydrochloric acid will stabilize not only lead but also §-
aminolevulinic acid (ALA).
stored lead. The decision to repeat chelation therapy is
based on the blood lead level after the “rebound.”
Reduction of lead intake is urgent for all children in
this category, both as part of immediate therapy and as
part of the followup preventive procedure. Children re-
ceiving chelation therapy should not be released from the
hospital until lead hazards in their homes and environ-
ment are controlled. Otherwise, suitable alternative hous-
ing must be arranged. Thus, the appropriate public
agency in the community must be notified immediately
so that environmental investigation and intervention can
begin.
After their hospitalization and after lead has been re-
moved from their environments, these children are still
at high risk. Close followup, with blood lead and EP mea-
surements, is required. At first, these tests should be
done every 1 to 2 weeks. If the blood lead level rebounds
to its pretreatment level, a repeat of the chelation therapy
should be considered. If the blood lead level remains
stable or shows a continual decline after the first few
weeks, the interval between testing may be incrementally
increased from 1 to 6 months until the blood lead and EP
levels return to normal or the child reaches 6 years of age.
HIGH RISK
Many children in the high-risk category will have been
given a calcium disodium EDTA mobilization test to
determine whether chelation therapy is needed. If it is
needed, inpatient chelation should be performed. Under
some conditions, however, children without urgent risk
factors may be treated as outpatients. Outpatient treat-
ment should be reserved, however, for those centers
capable of providing closely monitored outpatient care
and followup supervision, and in those centers it should
be provided only if the child’s source of lead exposure
has been eliminated (Piomelli et al., 1984). In addition,
the parents should be cooperative and should demon-
strate that they can follow instructions.
Followup of high-risk children should consist of blood
lead or EP tests, or both, at least monthly (especially in
the summer), until the sources of lead in their environ-
ments have been removed. If their blood lead or EP
levels have declined or stabilized, the interval between
testing may be incrementally increased, except in
summer, from 1 to 6 months, until the blood lead and EP
levels return to normal or the child reaches 6 years of age.
Careful neurological and psychological assessment is ad-
vised so that any behavioral or neurological deviation can
17
be detected early and proper therapy and school place-
ment begun.
MODERATE RISK
Generally, children in this category do not require che-
lation therapy. Reducing lead intake from all sources and
careful monitoring of the child usually suffices.
Until the lead hazards are eliminated from their envi-
ronment, these children should be tested monthly in the
summer and every 2 months in other seasons. If the
blood lead and EP levels remain stable or show a continu-
al decline after the first few months, the interval between
testing may be incrementally increased from 2 to 6
months until the blood lead and EP levels return to
normal or the child reaches 6 years of age.
NOTE: All children in the urgent-, high-, and
moderate-risk categories may have concomitant nutri-
tional deficiencies. These deficiencies may increase the
child’s risk from lead by increasing absorption, retention,
and toxicity. All children in these categories should re-
ceive a careful nutritional evaluation, including appropri-
ate laboratory tests. In addition to the care given for lead
toxicity, nutritional therapy should be provided. When in-
creased lead absorption is found, it may be particularly
important to correct iron deficiency and maintain an ade-
quate calcium intake.
LOW RISK
When tested, children in this category do not have sig-
nificant evidence of lead toxicity. However, they require
periodic screening until they reach their sixth birthday.
Children whose elevated EP levels are not caused by lead
absorption should receive medical attention and care for
the medical condition responsible for the elevation.
Children with elevated blood lead levels but no evidence
of toxicity should be evaluated monthly until lead toxicity
can be ruled out. This can usually be done within 3
months.
In conclusion, the clinical management of children
with lead poisoning must include appropriate treatment,
adequate followup, environmental intervention, and
family education. Chelation therapy is indicated for some
children with lead toxicity. Using it indiscriminantly is
unwise, but so is withholding or delaying it when it is in-
dicated. The physician providing clinical management
must know the current status of the child’s environment.
The optimal frequency of followup depends on many fac-
tors, including the child’s age and environment and the
trend in results of the child’s tests.
In the past, blistering, scaling, peeling, or powdering
paint was frequently removed only to a level of 4 or 5 feet
above the floor, because, usually, a small child can reach
no higher. However, dust or paint chips from unsound
lead paint above this level could fall into the child’s play
area. CDC now recommends that all unsound leaded
paint be removed from the interiors of dwellings, includ-
ing areas beyond the reach of children. Likewise, exterior
leaded paint (on porches, woodwork, and walls) that
either is in or can fall into the child’s play area should be
removed immediately. Places in and about the home
where young children spend much of their
time—namely, near windows, doors, and porches—are
particularly hazardous.
In summary, paint in unsound condition or on chewa-
ble surfaces is classified as an immediate hazard requiring
prompt abatement: other lead paint in sound condition
may not require immediate attention, but it must be
identified as a potential hazard.
Next, some common methods for reducing lead-based
paint hazards are outlined.
Phase I — Emergency Intervention
As soon as an elevated blood lead level is confirmed,
residents should be advised to remove all scaling paint
from places such as window sills, door frames, doors, and
porch railings that are within easy reach of the child. A
stiff brush should be used for this. Residents should also
be advised to avoid inhaling the dust or contaminating
other areas. The debris should be vacuumed and bagged
for safe disposal. Then the area should be thoroughly
scrubbed, preferably with high-phosphate detergents
such as Spic and Span (Milar and Mushak, 1982). If a crib
is next to a surface with scaling paint, the crib should be
moved away. Similarly, a piece of furniture should be
moved to prevent the child from reaching areas of scaling
paint. In the past, it was advised that window sills and
other wood trim with peeling paint be covered with mask-
ing tape or some other adhesive-backed paper. This is no
longer recommended. Inquisitive young children often
remove this tape, thereby rendering the technique inef-
fective. Families should be instructed on ways to keep
these areas free from loose or flaking paint until more
definitive steps can be taken to reduce the hazard. House-
keeping techniques such as frequent wet mopping and
damp dusting are essential in maintaining a reduced level
of hazard.
Phase II — Long-Term Hazard Reduction
Only when an old dwelling with lead-based paint is
gutted and completely restored can the lead hazards be
considered “permanently abated.” Less extensive, com-
monly used procedures may be called “long term”; how-
ever, how long the hazard will remain under control
depends on such factors as the thoroughness of the proce-
dure, the soundness of the underlying structure, and the
condition of the plumbing. Increased moisture from
leaky pipes behind walls can quickly cause paint that was
smooth and intact to blister and scale.
19
Abatement entails four steps:
1. Removing lead paint from wood trim or walls.
2. Thorough vacuuming to clean up the debris.
3. Wet scrubbing for maximum elimination of fine
lead-bearing particles.
4. Repainting the area with lead-free paint (that is,
paint containing less than 0.06% of lead in the final
dried solid).
The property owner’s responsibility is not met until all
four steps have been completed.
Just prior to and during abatement, certain precautions
are essential. Carpets, rugs, upholstered furniture, bed-
ding, clothing, and eating and cooking utensils must be
sealed as tightly as possible in plastic to protect them
from the enormous increase in lead-bearing dust created
by the removal procedures. Once items such as rugs are
impregnated with fine, lead-bearing particles, it is almost
impossible to remove the lead (Milar and Mushak,
1982). When feasible, this work should be carried out in
one room at a time, with the room closed off and all fur-
nishings removed. Until steps 1, 2, and 3 of the cleanup
process are completed, all young children and pregnant
women should live elsewhere both day and night. If this
is not possible, they, as well as the child with the index
case, should have serial blood lead tests before, during,
and after the abatement work. Those doing the work
should comply with OSHA standards; they should use re-
spirators and wear coveralls, which must not be taken to
the workers’ homes for laundering.
Walls
Removing lead paint from walls, particularly lead paint
applied to plaster, is usually difficult. In most cases, a bar-
rier, such as wallboard, hardboard, fiberglass, plywood
paneling or a similar durable, fire-resistant material, can
be placed over the lead paint on the walls. These materials
must be firmly nailed, cemented, or glued in place to pre-
vent the child from removing them. The barriers should
be verminproof and, in certain areas of the dwelling (that
is, next to furnaces and stoves and in common hallways),
fire retardant. Wallpaper painted with lead paint should
be stripped off to the maximum extent possible.
Woodwork
Lead-based paint in unsound condition on both interi-
or and exterior wood trim (for example, window units,
door units, stair risers, bannisters, and railings) presents
considerable danger for children. Paint can be removed
from wood surfaces by heat (from gas torches and heat
guns), sanding, scraping, and with liquid paint removers.
All of these methods are hazardous. Most solvents in
liquid paint removers evaporate rapidly and are flamma-
ble and toxic. These removers must be used with the
utmost caution and only in well-ventilated areas with
proper protective clothing and equipment. When the un-
derlying wood has rotted, no attempt should be made to
remove the paint. Instead, the wood should be replaced,
including, when necessary, entire window units and
doors or door frames. Exterior rotted wood should also
clothes and shoes before going home from work. This
standard now applies only to industries covered by OSHA
regulations. For the protection of children, it should be
extended to all industries that use lead. The prevention
of lead exposure to the fetus needs special emphasis.
Women of childbearing age should be excluded from
working at jobs where significant lead exposure occurs.
21
LEAD-GLAZED POTTERY
All glazed pottery used for foodstuff should be free of
leathable lead. Hobbyists and consumers should be
educated to the risks associated with pottery glazes.
Consumers should not use pottery for cooking or for stor-
ing food or beverages unless the pottery has recently
been determined to be free of leachable lead.
X. References
Angle CR, McIntire MS. Low level and inhibition of
erythrocyte pyrimidine nucleotidase. Environ Res
1978;17:296-302.
Annest JL, Pirkle JL, Makuc D, Neese JW, Bayse DD,
Kovar MG. Chronological trend in blood lead levels
between 1976 and 1980. N Engl J Med 1983;
308:1373-7.
Baker EL Jr, Folland DS, Taylor TA, et al. Lead poison-
ing in children of lead workers: home contamination
with industrial dust. N Engl J Med 1977,296:260-1.
Baker EL Jr, Hayes CG, Landrigan PJ, et al. A nationwide
survey of heavy metal absorption in children living
near primary copper, lead, and zinc smelters. Am J
Epidemiol 1977,106:4.
Barltrop D. The prevalence of pica. Am J Dis Child
1966;112:116-23.
Barltrop D, Khoo HE. The influence of nutritional factors
on lead absorption. Postgrad Med J 1975;51:795-800.
Beattie AD, Moore MR, Devenay WT, et al. Environ-
mental lead pollution in an urban soft water area. Br
Med J 1972;2:491.
Beloian A. Use of a food consumption model to estimate
human contaminant intake. Proceedings of the Inter-
national Workshop on Exposure Monitoring. Las
Vegas, Nev., USA, Oct. 19-22, 1981. Environ Monit
Assess 1982;2(1-2):115-28.
Benignus BA, Otto DA, Muller KE, Seiple KJ. Effects of
age and body lead burden on CNS function in young
children: II. EEG spectra. Electroencephalogr Clin
Neurophysiol 1981;52:240-8.
Billick IH, Shier DR, Curran AS. Relation of pediatric
blood lead levels to lead in gasoline. Environ Health
Perspect 1980;34:213-7.
Blumberg WE, Eisinger J, Lamola AA, Zuckerman DM.
The hematofluorometer. Clin Chem 1977;23(2):
270-4.
Buhrmann E, Mentzer WC, Lubin BH. The influence of
plasma bilirubin on zinc protoporphyrin measurement
by a hematofluorometer. J Lab Clin Med 1978;91(4):
710-6.
Burchfiel JL, Duffy FH, Bartels PH, Needleman HL. The
combined discriminating power of quantitative elec-
troencephalography and neuropsychologic measures
in evaluating central nervous system effects of lead at
low levels. In: Needleman HL, ed. Low level lead
exposure: the clinical implications of current research.
New York: Raven Press: 1980:75-89.
Byers RK, Lord EE. Late effects of lead poisoning on
mental development. Am J Dis Child 1943,66:471.
Caprio RJ, Margulis HL, Joselow MM. Lead absorption
in children and its relation to urban traffic densities.
Arch Environ Health 1974;28:195-7.
Cavalleri A, Baruffini A, Minoia C, Bianco L. Biological
response of children to low levels of inorganic lead.
Environ Res 1981;25:415-23.
Center for Disease Control (CDC). Increased lead ab-
sorption and lead poisoning in young children: a state-
ment by the Center for Disease Control. Atlanta: US
Department of Health, Education, and Welfare, 1975.
Center for Disease Control (CDC). Preventing lead
poisoning in young children: a statement by the
Center for Disease Control: April 1978. Atlanta: US
Department of Health, Education, and Welfare, 1978.
Charney E, Kessler B, Farfel M, Jackson D. Childhood
lead poisoning: a controlled trial of the effect of dust-
control measures on blood lead levels. N Engl J Med
1983;309(18):1089-93.
Chisolm JJ Jr. Treatment of lead poisoning. Modern
Treatment 1967,4(4):710-28.
Chisolm JJ Jr. The use of chelating agents in the treat-
ment of acute and chronic lead intoxication in child-
hood. J Pediatr 1968;73(1):1-38.
Chisolm JJ Jr. Lead poisoning. Sci Am 1971;224:15-23.
Chisolm JJ Jr. Relationship between level of lead absorp-
tion in children and type, age, and condition of housing
in Baltimore, Maryland, USA. In: Proceedings of the
International Conference on Heavy Metals in the Envi-
ronment: Heidelberg, West Germany. Edinburgh:
CEP Consultants, 1983:vol 1, 282-5.
Dallman PR. Blood and blood forming tissues; red blood
cells. In: Rudolph JM, Hoffman JIE, eds. Pediatrics.
Norwalk, Connecticut: Appleton Century Crofts,
1982:1035-87.
De la Burde B, Choate MS Jr. Does asymptomatic lead
exposure in children have latent sequelae? J Pediatr
1972;81:1088-91.
De la Burde B, Choate MS. Early asymptomatic lead
exposure and development at school age. J Pediatr
1975,87:638-42.
Facchetti S, Geiss F. Isotopic lead experiment: status
report. Brussels-Luxembourg: Office for Official Publi-
cations of the European Communities, 1982.
»
Piomelli S. Free erythrocyte porphyrins in the detection
of undue absorption of Pb and of Fe deficiency. Clin
Chem 1977;23(2 Pt 1):264-9.
Piomelli S. Blood lead concentrations in a remote Himala-
yan population. Science 1980;210:1135-7.
Piomelli S, Rosen JF, Chisolm JJ, Graef JW. Manage-
ment of childhood lead poisoning. J Pediatr
1984;105(4):523-32.
Piomelli S, Seaman C, Zullow D, Curran A, Davidow B.
Threshold for lead damage to heme synthesis in urban
children. Proc Natl Acad Sci USA 1982;79:3335-9.
Rabinowitz MB, Needleman HL. Temporal trends in the
lead concentrations of umbilical cord blood. Science
1982:216:25.
Rabinowitz MB, Needleman HL. Petrol lead sales and
umbilical cord blood lead levels in Boston, Massachu-
setts. Lancet 1983;63(1):8314-5.
Rabinowitz MB, Wetherill GW, Kopple JD. Kinetic anal-
ysis of lead metabolism in healthy humans. J Clin
Invest 1976;58:260-70.
Reeves JD, Yip R, Kiley VA, Dallman PR. Iron deficien-
cy in infants: the influence of mild antecedent infec-
tion. J Pediatr (in press), 1984.
Reigart JR, Whitlock NH. Longitudinal observations of
the relationship between free erythrocyte porphyrins
and whole blood lead. Pediatrics 1976;57:54.
Roels H, Buchet JP, Lauwerys R, et al. Impact of air pol-
lution by lead on the heme biosynthetic pathway in
school-age children. Arch Environ Health
1976,31(6):310-5.
Rosen JF, Chesney RW, Hamstra A, DeLuca HF, Mahaf-
fey KR. Reduction in 1,25-dihydroxyvitamin D in
children with increased lead absorption. N Engl J Med
1980;302:1128-31.
25
Royal Commission on Environmental Pollution. Ninth
report: lead in the environment. Presented to Parlia-
ment by command of Her Majesty. London: Her
Majesty’s Stationery Office, April 1983.
Saenger P, Rosen JF, Markowitz M. Diagnostic signifi-
cance of edetate disodium calcium testing in children
with increased lead absorption. Am J Dis Child
1982;136:312-5.
Sayre JW, Charney E, Vostal J, Pless IB. House and hand
dust as a potential source of childhood lead exposure.
Am J Dis Child 1974;127:167.
Seppalainen AM, Hernberg S. A follow-up study of nerve
conduction velocities in lead exposed workers. Neuro-
behav Toxicol Teratol 1982;4:721-3.
Winneke G. Neurobehavioural and neuropsychological
effects of lead. Letter. Lancet. Sept 4, 1982:550.
Wolnik KA, Fricke KL, Caspar SG, et al. Elements in
major raw agricultural crops in the United States. I.
Cadmium and lead in lettuce, peanuts, potatoes, soy-
beans, sweet corn and wheat. J Agric Food Chem
1983;31:1240-4.
World Health Organization (WHO), Task Group on En-
vironmental Health Criteria for Lead. Environmental
health criteria 3: lead. Geneva: WHO, 1977.
Yip R, Schwartz S, Deinard AS. Screening for iron defi-
ciency with the erythrocyte protoporphyrin test.
Pediatrics 1983;72:214-9.
Yule W, Lansdown R, Millar IB, Urbanowicz MA. The
relationship between blood lead concentrations, intelli-
gence and attainment in a school population: a pilot
study. Dev Med Child Neurol 1981:;23:567-76.
CaNa,-EDTA*'*
Only CaNarEDTA (calcium disodium versenate)
should be used for treatment of lead poisoning. Nar
EDTA (endrate disodium) should never be used for
treatment of lead poisoning, because it may induce fatal
hypocalcemia and tetany.
Mechanism of action. CaNa,-EDTA increases urinary
lead excretion 20- to 50-fold. CaNa,-EDTA does not enter
the cells; thus it removes lead from the extracellular
compartment. Indirectly, lead is reduced in the soft tissue,
central nervous system, and red blood cells.’
Route of administration and dosage. CaNa,-EDTA
may be given intravenously or intramuscularly. The pre-
ferred and most effective route is a continuous intravenous
infusion; a given dose is most effective if infused over 6
hours." CaNa,-EDTA should be diluted to a concentration
<0.5% in dextrose and water or 0.9% saline solution. When
administered intravenously as a single dose, it should be
similarly diluted and administered by slow infusion over 15
to 20 minutes. Intramuscular administration of CaNa,-
EDTA is extremely painful and should be given with
procaine (0.5%) by deep injection.
CaNa,-EDTA should not be given orally, because it may
enhance absorption of lead from the gastrointestinal
tract.
Dosages vary in different situations and are discussed
below. In all cases, courses should be limited to 5 days,
followed by at least 2- to 5-day intervals to allow recovery
from zinc depletion.
Toxicity. The kidney is the principal site of toxicity.
Renal toxicity is dose related, reversible, and rarely occurs
at doses <1500 mg/m?. The renal toxicity may be reduced
by assuring adequate diuresis. CaNa,-EDTA should never
be given in the absence of an adequate urine flow. Before
administering it intramuscularly in children in good clini-
cal condition, adequate oral intake of fluids must be
assured.
Precautions. During chelation with CaNa,-EDTA,
urine and its sediment, BUN, serum creatinine, and liver
function tests must be carefully monitored. The appear-
ance of protein and formed elements in urinary sediment,
and rising BUN and serum creatinine values signify
impending renal failure, the serious toxicity associated
with excessive or prolonged administration of EDTA.
Inasmuch as CaNa,-EDTA may deplete zinc stores and
cellular injury may be associated with zinc depletion,
CaNa,-EDTA should be used with great caution.
CaNa,-EDTA, used alone without concomitant BAL
therapy, may aggravate symptoms in patients with very
high blood lead levels. Thus it should be used exclusively in
conjunction with BAL when the blood lead level is >70
27
ug/dl or clinical symptoms consistent with lead poisoning
are present. In such cases the first dose of BAL should
always precede the first dose of CaNa,-EDTA by at least 4
hours.
pD-Penicillamine. D-Penicillamine is not licensed by the
Food and Drug Administration for the treatment of lead
poisoning. Its use for this indication is thus to be consid-
ered experimental. It is the only commercially available
oral chelating agent. It can be given over a long period
(days). Toxic side effects may occur in as many as 20% of
patients given the drug."
Mechanism of action. D-Penicillamine enhances urinary
excretion of lead, although not as effectively as CaNa,-
EDTA. Its specific mechanism of action is not well
understood.
Route of administration and dosage. D-Penicillamine is
administered orally. It is currently available in capsules
(125 and 250 mg). These capsules may be opened and
suspended in liquid, if necessary. The usual dose is 30
mg/kg. Side effects can be minimized by initiating therapy
with small doses, for example, 25% of the desired final
dose, increased after 1 week to 50% and again after 1 week
to the full dose, while monitoring for possible toxicity.
Toxicity. The main side effects of D-penicillamine are
reactions resembling those of penicillin sensitivity, includ-
ing fevers, rashes, leukopenia, thrombocytopenia, and
eosinophilia. Rarely, more severe and even life-threatening
reactions (autoimmune hemolytic anemia, Stevens-John-
son syndrome) have been observed. Anorexia, nausea, and
vomiting are infrequent. Of most concern, however, are
isolated reports of nephrotoxicity, possibly from hypersen-
sitivity reactions. For these reasons, patients should be
carefully and frequently monitored for clinically obvious
side effects, and frequent blood counts, urinalysis, and
renal function tests should be performed. In particular,
blood counts and urinalysis should be done twice weekly, at
least in the first 3 weeks of treatment. If the absolute
neutrophil count falls to <1500/ul it should be immediate-
ly rechecked, and treatment should be stopped if it falls to
<1200/ul. D-Penicillamine should therefore not be given
on an outpatient basis if there is any question about
compliance with appointments.
D-Penicillamine should not be administered in patients
with known penicillin allergy.
New agents. Dimercaptosuccinic acid and 2-3-dimer-
capto-propane-1-sulphonate are both water-soluble deriva-
tives of BAL. Although both appear promising and safe
and have been used successfully in treatment of other
heavy-metal poisoning, ‘these drugs are presently in the
investigative stage for the treatment of lead poison-
ing.'s 1?
4 hours, given either intravenously over 15 to 20 minutes
through a heparin lock or by deep intramuscular injection
mixed with procaine. The concentration of CaNa,-EDTA
should not exceed 0.5% in the parenteral fluid. Combined
BAL-CaNa,-EDTA therapy is given for a total of
days.
During treatment, renal and hepatic function and serum
electrolyte levels should be monitored daily. It is advisable
to measure the blood lead concentration daily. (It will be
necessary to interrupt the CaNa,-EDTA infusion for |
hour before this sample is obtained, to avoid a spuriously
high value). If the blood lead concentration reaches <50
ug/dl, as it may within 3 days of combined BAL-
CaNa,-EDTA therapy, BAL may be safely discontinued
and CaNa.-EDTA continued for a full 5-day course of
treatment. If measurements of blood lead cannot be
obtained in time, it is safe to continue BAL for the full
5-day course. Except under highly unusual circumstances,
CaNa,-EDTA should not be administered for more than 5
consecutive days.
A second course of chelation therapy may be required
after a 2- to 4-day interval, to be started with CaNa,-
EDTA alone or with concomitant BAL, depending on the
blood lead concentration. A third course may be required if
the blood lead concentration rebounds to a value =50
ug/dl within 7 to 10 days after treatment. Unless there are
compelling clinical reasons, it is highly desirable to allow 5
to 7 days before beginning a third course of CaNa,-
EDTA.
ASYMPTOMATIC CHILDREN WITH
INCREASED BODY BURDEN OF LEAD
Although children with increased body burden of lead
are clinically asymptomatic, it is likely that they have
pervasive metabolic effects involving heme synthesis,*
red cell nucleotide metabolism, vitamin D and cortisol
metabolism®~" and renal function,':* and subclinical neu-
robehavioral effects.®**' Some of these profound metabolic
and cellular effects of lead have been observed at blood
lead concentrations <25 g/dl. 0.0
Diagnostic assessment. In asymptomatic children it is
essential to have a firm diagnosis based on an elevated
blood lead level before treatment is initiated. Measure-
ments of blood lead concentration in capillary samples are
subject to contamination and should never be the only basis
for treatment. Treatment should be initiated only after a
confirmatory measurement of the venous blood lead con-
centration. Even when there is strong additional evidence
of lead poisoning, such as paint flakes in the abdomen or
lead lines in the bones on x-ray examination, it is prefera-
ble to wait for a confirmatory measurement of venous
blood lead. Although measurements of erythrocyte proto-
porphyrin may be helpful in evaluating overall toxicity,
29
blood lead measurement is the criterion on which to base a
decision as to whether chelation therapy should be consid-
ered. (The EP may increase initially during chelation
therapy.) Therapeutic decisions should also be based on
the results of the CaNa,-EDTA provocative test.
Chelation therapy
Blood lead concentration =70 ug/dl. If the blood lead
level is =70 ug/dl, BAL and CaNa,-EDTA should be
given, in the same doses and with the same guidelines as
for treatment of symptomatic lead poisoning without
encephalopathy.
A second course of chelation therapy with CaNa,-
EDTA alone may be required if the blood lead concentra-
tion rebounds to a value = 50 ug/dl within 5 to 7 days after
treatment. Unless there are compelling clinical reasons, it
is highly desirable to allow at least 5 to 7 days before
beginning a second course of CaNa,-EDTA.
Blood lead concentration 56 to 69 ug/dl. If the blood
lead value is between 56 and 69 ug/dl, treatment should be
limited to CaNa.-EDTA only.
CaNa.-EDTA is given for 5 days at a dose of 1000
mg/m’/day, preferably by continuous infusion (or in
divided doses intravenously as above). Alternatively, how-
ever. if environmental control of the lead hazards has been
achieved, this treatment may be given on an outpatient
basis, at a dose of 1000 mg/m?*/day, preferably by intrave-
nous infusion over | hour, with adequate hydration (250
ml/m’). As a least preferable option, CaNa,-EDTA may
be administered intramuscularly mixed with procaine, at
the same single daily dose of 1000 mg/m-* for 5 consecu-
tive davs. This route of administration may represent a
painful but practical alternative, when circumstances dic-
tate it.
During treatment, renal and hepatic function and serum
electrolyte levels should be monitored. A blood lead
concentration should be obtained at 72 hours of treatment
(it will be necessary to interrupt the CaNa,-EDTA infu-
sion for 1 hour before this sample is obtained, to avoid a
spuriously high value) to monitor the effectiveness of
treatment.
CaNa,-EDTA treatment should be continued for 5 days.
Except under highly unusual circumstances, it should not
be administered for more than 5 consecutive days.
A second course of chelation therapy, with CaNa,-
EDTA alone, may be required if the blood lead concentra-
tion rebounds to a value =50 ug/dl within 5S to 7 days after
treatment. Unless there are compelling clinical reasons, it
is highly desirable to allow a period of 5 to 7 days before
beginning a second course of CaNa,-EDTA.
Blood lead concentration 25 to 55 ug/dl. When the
blood lead value is persistently between 25 and 55 ug/dl
and accompanied by EP persistently >35 ug/dl, the
decision to proceed with chelation therapy should be based
5.0f
L
e
a
d
E
x
c
r
e
t
e
d
/
E
D
T
A
A
d
m
i
n
i
s
t
e
r
e
d
(u
g/
mg
)
ee | ° 1 1
300 40.0 700
Blood Lead (ug/dl)
Figure. Lead excretion ratio as a function of blood lead. Data expressed as decimal logarithm of CaNa,-EDTA excretion
ratio (ug lead excreted/mg EDTA administered) versus blood lead. There is a significant correlation (r = 0.466,
P < 0.001), with a slope of 0.014 and an intercept of —0.95.
Data shown were obtained by different techniques. At Columbia University, 77 children in an outpatient setting
received CaNa,-EDTA as a 20-minute intravenous infusion at a dose of 50 mg/kg, followed by 250 mi/m’ 5% dextrose
over | hour: urine was collected for 7 to 8 hours. At Albert Einstein College of Medicine (Montefiore Hospital), 37
hospitalized children received CaNa,-EDTA intramuscularly with procaine at a dose of 500 mg/m? urine was collected
for 8 hours. At John Hopkins University School of Medicine, 50 hospitalized children received CaNa,-EDTA
intramuscularly at a dose of 25 mg/kg at 0 and 12 hours: urine was collected for 24 hours. At Children’s Hospital Medical
Center, 46 children in the outpatient clinic received CaNa,-EDTA intramuscularly with procaine at a dose of 50 mg/kg:
urine was collected for 6 to 7 hours. Despite these differences, slopes and intercept of regression lines were remarkably
similar: excretion ratio makes the CaNa,-EDTA provocation test independent of both the dose administered and the
child's age and body weight. Therefore, data could be pooled together in a single regression line. Combined data represent,
to the best of our knowledge, the largest series of CaNa,-EDTA provocation tests in children.
a laboratory where the volume can be measured with
lead-free equipment and aliquots for lead and creatinine
measurements can be taken without contaminating the
sample.
INTERPRETATION OF CaNa,-EDTA PROVOCATION TEST.
The concentration of lead in the urine (in micrograms per
milliliter) is multiplied by the volume (in milliliters), to
obtain the total excretion (in micrograms). The total
urinary excretion of lead (micrograms) is divided by the
amount of CaNa,-EDTA given (milligrams) to obtain the
“lead excretion ratio’:
Lead excreted (ug)
CaNa,-EDTA given (mg)
The CaNa,-EDTA provocation test is considered positive
if the lead excretion ratio exceeds 0.60.
The recommendations of the authors are based on their
experience with 210 provocation tests'?¢3%3 (Figure).
31
Inspection of the Figure shows that a ratio >0.60 is never
obtained in 12 children with blood lead level <30 ug/dl,
and is always obtained in 19 children with blood lead level
>60 ug/dl. At blood lead level 30 to 39 ug/dl, the ratio is
>0.60 in six (11.5%) of 52 children; at blood lead level 40
to 49 ug/dl the ratio is >0.60 in 25 (37.9%) of 66 children;
and at blood level 50 to 59 ug/dl the ratio is >0.60 in 30
(49.2%) of 61 children.
It appears, therefore, that a ratio <0.60 represents an
appropriate cutoff point to distinguish children with
“markedly increased” excretion. (It is not possible to
define a normal excretion range because no data are
available and it would be unethical to obtain them in
children with blood lead values <25 ug/dl. In addition,
even the lower blood lead levels observed in children from
industrialized countries are significantly higher than those
in children from remote areas uncontaminated by lead,
which most likely represent the truly normal blood lead
level. However, extrapolation from these data predicts, at
(primary residence, homes of relatives and baby sitters,
schools, daycare centers) and evaluation of each building's
age and state of repair. In the United States a high
proportion of buildings constructed prior to 1960 have
lead-bearing paints and putty on both exterior and interior
areas accessible to the child. Structures in poor repair often
have lead-containing chips or pulverized fragments in the
household dust. Play areas, especially urban playgrounds
near vehicular traffic, dirt playgrounds and dirt yards,
painted metal fences and walls, and vacant lots formerly
containing lead-painted structures should be identified as
potential lead sources. Occupational histories for all adults
in various dwellings should be ascertained to learn if any
are working in lead-related industries. Lead trades include,
but are not limited to, secondary lead smelting (recovery of
lead from old storage batteries), lead scrap smelting,
storage battery manufacturing and repair, metal founding,
ship breaking, automobile assembly and body and radiator
repair, demolition of painted metal structures (such as
bridges), and demolition and renovation of old houses and
other structures. Adults who work in lead industries must
shower before coming home and must leave all work
clothes, including shoes, at the work place; these clothes
must not be cleaned or washed at home. Thus lead-bearing
dust from the place of employment will not contaminate
the house. Additional sources may include old lead-painted
cribs and beds and the burning of lead-painted wood in
wood-burning stoves. Proximity to lead smelters, ingestion
of lead-containing dust, and inhalation of lead from the
combustion of gasoline contribute to the overall body
burden of lead in children, but the high concentration of
lead that ultimately results in clinical lead poisoning is
most frequently associated with ingestion of lead-bearing
paint. Uncommon causes of poisoning include ingestion
and retention in the stomach of metallic lead (fishing
weights, curtain weights, shot, jewelry painted with lead to
simulate pearl), contamination of acidic foods and bever-
ages from improperly lead-glazed ceramic pitchers, pots,
and cups and from opened lead-soldered food cans, and the
home burning of battery casings. Inhalation of fumes
(sniffing) from small leaded-gasoline containers has
occurred in older children. Poisoning has also been traced
to oriental cosmetics (surma, a black eyeliner containing
up to 85% lead) and to Mexican and Oriental folk
remedies (azarcon, greta, paylooah).
Medical management during abatement of lead paint
hazards. If the source of lead is limited to such items as
retention of a metallic lead object in the stomach or an
improperly lead-glazed food or beverage container, the
child can be promptly separated from the source. Such is
not the case when lead paint in the home is the principal
source. Several methods are used to remove old lead-based
33
paint from walls and woodwork. Some methods, particu-
larly removal by burning and sanding, greatly increase the
amount of air and dustborne lead in the home. Very fine
lead-bearing particulates settle out slowly over many hours
after burning and sanding is completed. It is of the utmost
importance to remove all young children and pregnant
women from a dwelling until the abatement process is
completed. They should live elsewhere day and night, and
should not return until removal of all lead-bearing paint
has been completed and the dwelling has been thoroughly
vacuumed and scrubbed with high-phosphate-detergent
solutions. The sources that have been denuded during the
abatement process should be repainted to seal any residual
lead behind the surface. Children should be removed from
the home during abatement whether or not they have
increased lead absorption. When this procedure is not
followed, it is not uncommon to observe 30 to 50 ug/dl
increments in whole blood lead concentration within a
matter of a few days or weeks.
Long-range dust control. [1 must be understood that
dust control is not a substitute for abatement. In areas
heavily contaminated with lead, such as deteriorating old
housing and dwellings adjacent to lead-emitting industrial
plants or heavy vehicular traffic, it may be helpful to
institute a regular program in and about the home to
control lead-bearing dust, which constantly reaccumulates.
Because hand-to-mouth activity is common in young
children, parents must institute a specific type of cleaning
program; vacuuming and wet cleaning are recommended.
Sweeping with a broom, although it may remove large
fragments, serves only to stir up smaller particulates. It is
recommended that all floors and woodwork be scrubbed
weekly with high-phosphate detergents such as Tide or
Spic and Span. For all surfaces that the child can touch,
the weekly scrubbing should be supplemented with daily
damp dusting with a cloth rinsed in a solution of high-
phosphate detergent. Although such cleaning programs
may be helpful, the definitive way to prevent recurrences is
for affected children and their families to move into
housing free of lead paint hazards.
Dietary factors. Although reduction in exposure to
environmental lead must receive first priority, steps should
be taken to identify and correct deficient dietary intake,
particularly of calcium® ** and iron as well as excessive
dietary fat, each of which may increase the absorption and
retention of lead. A diet adequate in minerals and limited
in fat should be assured. For those intolerant of cow milk,
lactose-free milk products such as yogurt or some alterna-
tive source are necessary to ensure adequate calcium
intake. The use of low-fat milk and the avoidance of fried
foods should limit excessive dietary fat. Acidic foods such
as fruits, fruit juices, tomatoes, sodas, and cola drinks may
23.
- Hammond PB: The effects of chelating agents on the tissue distribution and excretion of lead. Toxicol Appl Pharmacol 18:296, 1971.
. Leckie WJH, Tompsett SL: The diagnostic and therapeutic use of edathamil calcium disodium (EDTA. versene) in excessive inorganic lead absorption. Q J Med 27:65, 1958.
atrics 29:384, 1962.
- Teisinger J, Srbova J: The value of mobilization of lead by calcium ethelene diaminetetraacetate in the diagnosis of lead poisoning. Br J Ind Med 16:148, 1959. . Hansen JPB, Dossing M, Pauley PE: Chelating lead body burden (by calcium-disodium EDTA) and blood lead concen- tration in man. J Occup Med 23:39, 198; - Lahaye D, Roosels D, Verwilghen R: Diagnostic sodium calcium edetate mobilization test in ambulant patients. Br J Ind Med 25:148, 1968.
. Chiesura P: Remarks on the use of shortened procedures in evaluating EDTA-induced urinary lead excretion. Lavoro Umano 28:97, 1976.
. Vitale LF, Rosalinas-Bailon A, Folland D, Brennan JF, McCormick B: Oral penicillamine therapy for chronic lead posioning in children. J PEDIATR 83:104]. 1973. . Graziano JH, Leong JK, Freidheim E: 2.3-Dimercaptosuc- cinic acid: A new agent for the treatment of lead poisoning. J Pharmacol Exp Ther 206:696. 1978.
- Aposhian VH: DMSA and DMPS water-soluble antidotes for heavy-metal poisoning. Ann Rev Pharmacol Toxicol 23:193, 1983.
. Piomelli S, Seaman C, Zullow D. Curran A, Davidow B: Threshold for lead damage to heme synthesis in urban children. Proc Natl Acad Sci 79:3335, 1982. . Piomelli S: A micromethod for free erythrocyte porphyrins: The FEP test. J Lab Clin Med 81:932, 1973. . Chisolm JJ Jr: Heme metabolites in blood and urine in relation to lead toxicity and their determination. Adv Clin Chem 20:225, 1978.
Alessio L. Bertazzi PA. Toffoletto F, Foa V- Free erythrocyte protoporphyrin as an indicator of the biological effect of lead in adult males. Int Arch Occup Environ Health 37:73, 1976.
26.
31.
32.
33
34.
- Angle CR, McIntire MS, Swanson MS, Stohs SJ: Erythro- cyte nucleotides in children: Increased blood lead and cytidine triphosphate. Pediatr Res 16:331, 1980.
. Rosen JF, Chesney RW, Hamstra A, DeLuca HF, Mahaffey KR: Reduction in 1.25-dihydroxyvitamin D in children with increased absorption. N Engl J Med 302:] 128, 1980. Mahaffey KR, Rosen JF, Chesney RW. Peeler JT, Smith CM, DeLuca HF: Association between age, blood lead concentration and serum 1.25-dihydroxycholecalciferol levels in children. Am J Clin Nutr 35:1327, 1982. . Saenger P, Markowitz ME, Rosen JF: Depressed excretion of 68-hydroxycortisol in lead-toxic children. J Clin Endocrinol
. Needleman H, Gunnoe C, Leviton A, Reed R, Peresic H, Maher C, Barrett Pp: Deficits in psychologic and classroom performance of children with elevated dentine lead levels. N Engl J Med 300:689, 1979.
. Winneke G. Kramer U, Brochkaus E, Ewers U, Kajanek G. Lechner H, Janke W: Neuropsychological studies in children with elevated tooth-lead concentrations: Extended study. Int Arch Occup Environ Health 51:232, 1983. . Otto DA, Benignus V. Muller K. Barton CN: Effects of age and blood lead burden on CNS function in young children. |. Slow cortical potentials. Electroencephalogr Clin Neurophy- siol 5§2:229, 1981.
Otto DA, Benignus V, Muller K. Barton CN, Seiple K, Prah J. Schroeder S: Effects of low to moderate lead exposure on slow cortical potentials in young children: Two-year follow-up study. Neurobehav Toxicol Teratol 4:733, 1982. Graef JW: Outpatient use of a six-hour lead mobilization test in chelation therapy [abstract]. Pediatr Res 10:330, 1976. Chisolm JJ Jr. Barret MB. Harrison HV: Indicators of internal dose of lead in relation to derangement in heme synthesis. Johns Hopkins Med J 137:6, 1975. Piomelli S, Corash L. Corash MB, Seaman C. Mushak P, Glover B, Padgett R: Blood lead concentrations in a remote Himalayan population. Science 210:1135, 1980. . Sorell M, Rosen JF, Roginsky M: Interations of lead, calci- um, vitamin D and nutrition in lead-burdened children. Arch Environ Health 32:160, 1977.
Notes
Notes
Notes
CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
Medical Guidelines
December 31, 1982
£7 vite Zz,
Beverlee A. Myers, Director /
Adopted by the California State Department of Health Services
As Required by Section 321(b) of the Health and Safety Code
Beverlee A. Myers, Director
December 31, 1982
MEDICAL GUIDELINES
Child Health and Disability Prevention Program
The following guidelines for a health assessment have been developed to aid in the screening proce-
dures, evaluation, health education, and follow-up services outlined in the Child Health and Dis-
ability Prevention (CHDP) Program enabling legislation (Section 321.2, Health and Safety Code)
and in its implementing regulations (Section 6846, California Administrative Code). Many services
and procedures in the following text are mandated by the CHDP Program legislation and/or regula-
tions. The “Health Assessment Procedures For Various Age Groups” table on page 2 provides a
schedule of screening procedures appropriate for specific age groups.
These guidelines describe the required screening procedures as well as tests and include recom-
mended criteria for appropriate referral to diagnosis and treatment. A person with a suspected
condition as indicated by the health assessment (and who is not currently receiving care for that
condition) must be offered diagnostic and treatment services. The comprehensive care provider is to
give care that is in his/her area of expertise. Otherwise the child must be referred to the usual source
of health care or to appropriate providers accessible to the family.
It is the health provider's responsibility to assure that paraprofessionals doing developmental or
other parts of the CHDP health assessment are adequately trained, that they understand the sensi-
tivity of the procedure as well as the delicateness of communicating with the parent or person
receiving the health assessment, and that discussion of screening results with a parent or person
being screened be free of diagnostic statements or suggestions that the person screened needs any
particular treatment. When the health assessment is done by paraprofessionals, the supervising
physician should verify the existence of more serious conditions (e.g., heart murmur, scoliosis, a
developmental problem, etc.).
Developmental assessment and other components of the CHDP health assessment are sensitive areas.
When making a referral for diagnosis and/or treatment, screening providers should relay only
information which avoids labeling or making a premature diagnosis. They should say only that a
suspected condition was referred or that a diagnostic and treatment service is needed.
When a child is suspected of having a California Children Services (CCS) eligible condition, the
provider must inform the family of the availability of the CCS program services and the child must
be referred to CCS if requested by the family. CCS referral criteria and procedures may be found in
Appendix A.
MEDICAL GUIDELINES
Child Health and Disability Prevention Program
Department of Health Services
The Child Health and Disability Prevention (CHDP) Program is a public health, well-child program
providing health assessments for the early detection and prevention of disease and disabilities in
children. The goal of the Program is to serve all persons eligible for CHDP services with quality care
by practitioners who relate to the physical, mental, and emotional health of children and youth
within the context of the family.
The State of California Department of Health Services is empowered under Section 321 of the
Health and Safety Code to adopt, with the advice and recommendations of the State Maternal,
Child, and Adolescent Health Board, “standards for health screening, evaluation, and diagnostic
procedures for child health and disability prevention programs.” These guidelines relate to the
health screening and evaluation procedures described in CHDP legislation (321.2, Health and Safety
Code) and regulations (Section 6846, California Administrative Code).
The purpose of the CHDP Medical Guidelines is to set a standard for services including the fre-
quency and content of examinations, the definitions of tests, and acceptable criteria for referral for
further diagnosis. It is the intent of the CHDP Program that eligible children will receive all
examinations and appropriate tests except when deemed to be contraindicated by the provider,
recently done and therefore not needed, or refused by the patient and/or parent. The guidelines are
not designed to constrain the examiner from doing a more extensive examination or from using
similar but equivalent tests, as long as they are performed and billed within the regulations of the
CHDP Program.
The guidelines are designed to take into account the variability of resources in local areas, accom-
modate differences in individual and clinic modes of operation, recognize differences in public and
private medical practice, and to allow the necessary flexibility required by these differences. For
purposes of completeness, the guidelines also include relevant requirements mandated in the CHDP
legislation.
The guidelines were prepared by the CHDP Branch of the Department of Health Services in con-
sultation with the State Maternal, Child, and Adolescent Health Board’s technical advisory
committee. The final draft was distributed to interested parties and presented for review and
recommendations at a public meeting of the State Maternal, Child, and Adolescent Health Board.
Changes were made based on comments by providers, professional organizations, and professionals
within the Department of Health Services. The guidelines were subsequently officially received and
recommended for adoption by the State Maternal, Child, and Adolescent Health Board. This
recommendation was conveyed to the Director of the Department of Health Services.
We know that quality care and comprehensive services occur because of the dedication and concern
of those of you serving CHDP families. We hope that the Medical Guidelines will be of help to you
in planning and providing the services which the CHDP Program regulations specify.
Siegried A. Centerwall, M.D., Chief
Child Health and Disability Prevention Branch
MEDICAL GUIDELINES
TABLE OF CONTENTS
Page
INTOQUCHONY, . . ce vi ts is ainitie sain sa lle a 0 x ohTee #0e aig wise mn wa x + Wot vin iw Ee 1
Child Health and Disability Prevention Program Health Assessment, Evaluation,
Referraliand FollOW-UD SerVICeS , . uta ssid te sine swims vinibin nie vo ninnini ¥iuen 1
Health Assessment Procedures Required for Various Age Groups ............... 2
Health Story. cl Sh ose vin» vieieininin + 50 + 53 on in whe os niminon te SF ay» aah lide 3
PhysicaliEXamINAtION .. J, ues sien sais Halas iter sisialitnae a wu sin ts on v's wx u0 4 ln nities 3
Helohtand Welght i. iit Fi slecen se tdie nies sie tse thaiv vino aT a ve x 3
Head CI CUMTCIENCE «16 rr. sia sles tres sien sere mn Tn wd on + oil saleiuts on bin + 0 4
Blood Pressure cn he ae alls Sa a a aie 5
Arterial PUSES or. i a a a le a se a Te ane % 5
Dental ASSESSOR i, oie rs viaseine = vhs’ 4 siniedger = tins s 2isivio ies VIB # vir x dik uin wikin o 3 6
EX amination Of SPINE... Ns te nt er as a nie way ok ne ny ei 6
Breast Self EXarminatiOnN i, 1s ste oles soins vis sirivn sivinioio nis diate’ ns » mins oo distin ok 6
Child ADUSE hi entrees asian sale « sina sale nis aioonle's ann dia nin sw ibre Lids 0 40 » 7
Nutr/HONRAT ASSESSTNEIT ote, so sislitisie sins inaain x #is wins Bobeca + Wade's wiaiw nn on iain i'n wits 7
Criteria for Identifying Nutritional Problems . .. . . ..... 0... 0a vi dons 8
Developmental HiStozy and ASSESSIIENE , ...., . uo ul cdvdiniei™ ys sisivn 'n slinie sis on viv vin ole 9
Developmental GuIBeRNeS oasis oo ocr ov Winine wesinin maine o sinlinw sins « sinie'n vin » 10
Health EQUCAtION (cis, oon sins stnio alfins sina ns +00 4 5 v0 nn 4iain minions 1 ae 45% 5 5 x ws shuinie.s 14
Definition, Process, and RESOUICES . . . . i cu. . culuic ot cosines itn ss iain snsnens sees 14
Sugcested Health EQUcation TOPICS DY AE + vve vist tairv er renne vn nsmninnens 15
Additional Required Screening Procedures
VIS ON SS CTCOIING i. soit trina s sininis ov tin siete vine signe vin vis wus bine nanininien 20
Hearing SCIEN. . oc civil sini van reas itnn sini ns sliininine vo uxt 500 no Bmninies 21
Spi cil VS TROT TE Teg SO SEER SSN NEM Le 23
Hematocrit or Hemoglobin . coi «20 de vie vo sien sannndosnees vib vo wnimssnmnss 23
Urine Dipstick or Urinalysis, . «leave feet Sie sidee wis nis xt wn vim ain wins » 24
Papamicolau(PapySMear vi. « « sve svt cai cnn anny rrlnurie sR as rare s 25
12/82 ii
Screening Procedures When Medically Indicated Pass
Phenyiketonuria {PRUY wo. Jo, fonivi se mina «ovoid sien» vin bo aidhatiten 5 wine vd 25
Sickie CelliDetermination . .c. 8sic id as CW Svan winnie ob Rain iein sin ein alu o foe 25
Free Erythrocyte Protoporphyrin (FEPY .. ..... vc vnsivnni ev cviy vena, 26
Blood lead Level . oh. tui hi tail ce calls vias wh wR phe a a 26
GonorTREa Culture 60 a. vit dannii sien rie da alee as Sp 26
Laboratory Test and Procedure Rechecks: .. opin «oie vile solf au vnisie dunes «os 27
Screening Procedures Requiring Prior Approval ................. oii 27
Immunizations. . . 6. CR se EG ye eae sa ee we ey rns 27
Recommended Immunization Schedule... ..o cc. ctv vivid saenn 28
INDE Xs in ai oe eis ae nies lee vw A Sie i sale k ee ie ee 42
APPENDIX
A Referral of Children to California Children Services .. ....... coe cvnitnrin oh 31
B Guidelinesfor Body Weight 1: a. oii vinnie anes shiin, vainasine sw vais 32
C Scoliosis Screening and Referral Criteria... ..... hn. Live ms vii, 33
D Child Abuse—Medical and Non-Medical Practitioner’s Responsibilities . . . ......... 34
E Women, Infants, and Children Supplemental (WIC) Food Program .............. 38
F ooThe Worth Four-Dot Test. |. cu ce ainivnings simian swim vive sin i sleis agtlines uy 39
G Puretone Audiometric Screening Qualifications and Standards ................. 41
HEALTH ASSESSMENT PROCEDURES h. JIRED FOR VARIOUS AGE GROUPS'
Child Health and Disability Prevention Program
AGE OF PERSON BEING SCREENED
Under| 1-2 | 3—4 | 5-6 7-9 | 10-12 | 13-15 16-23 2 3 4-5 | 6-8 | 9-12 13-16 | 17-20
SCREENING PROCEDURE
1 Mo. | Mos. | Mos. | Mos. | Mos. Mos. Mos. Mos. | Yrs. | Yrs. | Yrs. Yrs. Yrs. Yrs. Yrs.
Interval Until | 1 mo. 12 Mos. (2 Mos. |2 Mos. 3 Mos.| 3 Mos. | 3 Mos. | 6 Mos. | 1 Yr. | 1 Yr. 2 Yes. |3Vrs.| 4 Yrs. | 4 Yrs. | None
Next Exam
HISTORY AND PHYSICAL EXAMINATION X X X X X X X X X X X X X X X
Dental Assessment
Nutritional Assessment
Developmental History and Assessment
Ro Health Education
VISION SCREENING
Snellen or Equivalent Visual Acuity Test
X*? X X X X X
Clinical Observation x IX x Ix hx X X X X 7X] x 1x X X X
HEARING SCREENING
Audiometric
%x3 X X X X= lox
Nonaudiometric
X X X X X X X ) 4 X
5
TUBERCULIN TEST?
X
X X X
LABORATORY TESTS
Hematocrit or Hemoglobin
X X X X X X X X
Urine Dipstick or Urinalysis
X X X X X
Phenylketonuria (PKU)
X
w Sickle Cell
May be done once if both anemic and from specific target groups (see guidelines).
Free Erythrocyte Protoporphyrin (FEP)
May be done only if health history warrants.
Blood Lead Level
May be done only if FEP is above 35 ug/dl.
Gonorrhea Culture*
X X X
ro.
Papanicolau (Pap) Smear
x4 X
IMMUNIZATIONS — administer as X X X X X X X X X X X X X X
necessary to make status current.’
NOTE: PERSONS COMING UNDER CARE WHO HAVE NOT RECEIVED ALL THE RECOMMENDED PROCEDURES FOR AN EARLIER AGE SHOULD BE
BROUGHT UP-TO-DATE AS APPROPRIATE.
1 Required unless medically contraindicated or deemed Inappropriate by the screening provider or refused by the person.
2 Snellen and audiometric examinations should be done at this age If possible.
Ly
3 Recommended more frequently In high risk populations such as recent Immigrant and refugee families.
4
6
Recommended only for sexually active adolescents.
*Gulide For Use of Selected Vaccines and Toxolds,” Californie Department of Health Services, Infectious Disease Section, July 1980.
Reference: CHOP Legislation, Health and Safety Code, Sections 321.2 and 323.7.
(3 8 /8 5)
~
£
HEALTH HISTORY
A health history is a very important aspect of the periodic health assessment and should include,
but is not limited to, information in the following areas:
Social, cultural Allergies
Environmental Illnesses
Family health Accidents
Prenatal, birth, neontal Hospitalizations
Development Immunizations
Physical growth Communicable diseases
Nutrition Parental concerns
PHYSICAL EXAMINATION
A physical examination must be given while the patient is unclothed. Attention, therefore, should
be given to the age of the patent and his/her need for privacy.
The physical examination shall include, but is not limited to, the following:
Height:
Weight:
Skin Neck Extremities
Hair Chest Palpation of femoral and
Head Lungs brachial (or radial)
Eyes Heart pulses
Ears Spine Blood pressure
Nose, throat Abdomen Height and weight
Mouth, teeth, gums Genitalia Head circumference
HEIGHT AND WEIGHT
Measure infant and small child’s length (to the nearest % inch) using a stan-
dard measuring board. Children who can stand should be measured using a
right-angle head board and a standard measuring tape or yardstick attached to
a flat wall with no baseboard or molding. Measurements should be made to
the nearest % inch without shoes.
Measuring rods attached to scales should never be used because the surface on
which the child stands is not stable, and the measuring rod’s hinge tends to
become loose, causing inaccurate readings.
Record on the National Center for Health Statistics (NCHS) Growth Charts
(1976) of height-for-age.
Weigh the infant and child under two years to the nearest % ounce and weigh
older children to the nearest % pound. A beam balance which is regularly
checked for accuracy is preferred.
Record on the NCHS growth chart of weight-for-age.
Weight for Height: This relationship should be recorded on the NCHS growth chart.
The use of the NCHS growth charts as both a screening and educational tool
is recommended. These represent the normal growth patterns of children
regardless of their genetic endowment. Children with short parents may be
growing normally even if they are below the 5th percentile level of height-for-
age.
The important factor for them is their growth pattern and their weight-for-
height relationship. If a child is reaching his growth potential, he should main-
tain similar percentile levels on all charts except when he is experiencing
catch-up growth (a growth spurt).
When there is a significant change in percentile levels between two visits, the
data should be checked for measurement error and, if correct, the child
should be watched closely for failure to thrive, development of obesity, or
some other pathology.
Referral and Follow-Up
If the nutritional evaluation indicates improper eating patterns, nutritional education before the
child or adolescent reaches the cut-off levels may prevent problems (see “Criteria for Identifying
Nutritional Problems Requiring Follow-Up or Referral” table on page 8).
Further evaluation is needed at the following levels:
Infants and Prepubertal Children
1. Overweight—above 95th percentile for weight-for-height.
2. Underweight—below the 5th percentle for weight-for-height.
3. Short stature—below the Sth percentle for height-for-age.
4. Significant change in the percentile levels from one measurement to the next or over a
period of several months or years.
Adolescents
The table in Appendix B is recommended as the standard. Adjust for age by subtracting one pound
for each year below age 235.
1. Underweight—10% below the average value of weight-for-height.
2. Overweight—20% above the average value of weight-for-height.
HEAD CIRCUMFERENCE
The head should be measured at the largest circumference at each visit up to 12 months of age and
plotted on the National Center for Health Statistics growth chart for head circumference.
Further evaluation is needed if the NCHS growth grid reveals significantly changed percentile levels
from one measurement to the next or over time.
12/82
BLOOD PRESSURE
Blood pressure measurement is a routine part of the physical examination at three years of age and
older. It is technically difficult to obtain an accurate blood pressure reading during infancy; there-
fore, it is taken in this age group only if other physical findings suggest it may be needed.
Appropriate cuff size is essential for recording accurate pressure readings. References to cuff size
apply only to the inner inflatable bladder rather than to the cloth covering, the inner bladder
usually being significantly narrower and shorter than the cloth covering. Selection of the largest
cuff that will snugly fit the child’s arm or leg without the inner bladder overlapping will give more
accurate readings.
Because of lability of the blood pressure in children, measurements that are high or in the high
normal range should be repeated later in the visit.
Referral and Follow-Up
Counseling and surveillance should be provided to children who are asymptomatic and whose
initial blood pressure is consistently in the high normal range, i.c., within 5 mm Hg of the referral
criteria as below.
Referral for diagnosis and treatment is required if the blood pressure in the right arm is elevated
according to the following critena:
CRITERIA FOR CRITERIA FOR
COUNSELING AND DIAGNOSIS AND
AGE SURVEILLANCE TREATMENT
Under 8 Years 115/75 to 120/80 Over 120/80
8 Through 12 Years 125/80 to 130/85 Over 130/85
Over 12 Years 135/85 to 140/90 Over 140/90
ARTERIAL PULSES
The femoral and brachial (or radial) pulses are to be taken. The rate and quality of the pulses are
to be noted.
Referral and Follow-Up
Referral is made if any of the pulses are absent to palpation.
DENTAL ASSESSMENT
Most dental disease can be prevented and the examiner can play a vital role in its prevention. Dental
inspection presents the opportunity to instruct persons in proper hygiene procedures as well as to
detect serious problems with the teeth and gums. Dental health education, stressing a good diet with
minimum sweets, adequate intake of fluoridated water or fluoride supplement (if the water supply
is not fluoridated), and daily brushing and flossing of the teeth, should be included in the assess-
ment.
Dental screening shall include inspection of the teeth and gums for any signs of infection, abnor-
malities, malocclusion, inflammation of gums, plaque deposits, caries or missing teeth.
Referral and Follow-Up
All children with active infection, pain, or severe problems are to be referred for immediate diagno-
sis and treatment. Children with other dental problems should be referred within a reasonable
period of time for diagnosis and treatment. Only these children should be given a referral form
(known dental problem). Other children over three years of age should have the benefit of definitive
dental diagnosis and remedial treatment and should be seen by a dentist at least annually. (There is
no need to indicate a 5 code on the PM 160 in these instances.)
EXAMINATION OF THE SPINE
Examination for asymmetry of the body posture is to be done by observing the body in several
positions. Scoliosis screening and referral criteria, which was developed for school programs by the
State Department of Education, may be found in Appendix C.
Referral and Follow-Up
Further evaluation, diagnosis, and treatment is indicated if any of the following findings are
present:
High shoulder
Curved spine
Uneven hip or waist creases
Uneven nipple line
Unequal arm to body space on both sides
Accentuated round back or accentuated swayback A
W
N
bh
W
w
BREAST SELF-EXAMINATION
Instruction in breast self-examination should be given when females reach adolescence. Remind
patients that the procedure should be practiced once a month about a week following each men-
strual period.
12/82
CHILD ABUSE
Medical practitioners are generally acknowledged as being the first line of defense against child
abuse because they are often the first persons to see the child and are best able to recognize signs of
abuse.
State law requires that when a medical or nonmedical person has even a “reasonable suspicion”
that a child may be neglected or abused, the case shall be reported immediately to either local child
protective services or local law enforcement agencies.
Child abuse is defined as (1) physical abuse and injurious corporal punishment; (2) physical neglect;
(3) sexual abuse and (4) emotional abuse or mental suffering.
Appendix D covering the medical and nonmedical practitioner’s responsibilities with respect to
child abuse is included for your information.
NUTRITIONAL ASSESSMENT
The evaluation of nutritional status is based on information obtained from the history and physical
including height and weight, diet, growth pattern, hemoglobin and/or hematocrit and dental
inspection.
The dietary history should include food intake, the use of vitamin and mineral supplements, pica
behavior, present or past food-related illnesses such as food allergies, diarrhea or chronic constipa-
tion, and social, cultural, and environmental conditions that affect food intake. A plan should be
made for remediation of any problems which then become a part of the child’s medical record.
The most common nutritional problems found in California which require education, referral to
a nutritionist and/or further diagnosis and treatment are: failure to thrive, stunted growth, under-
weight or overweight for height, iron deficiency anemia, inappropriate feeding practices for infants,
i.e.., unmodified cow’s milk prior to six months, cereal and strained food added to bottle, early
addition of solid foods, more than 32 ounces of formula or milk per day and dental problems.
Some nutritional problems can be prevented or corrected by appropriate education given by the
"screening personnel at the time of the screening. Complex problems require a more complete
assessment and intervention by a nutritionist, such as that available in the Women, Infants, and
Children (WIC) Supplemental Food Program. See Appendix E for WIC referral criteria. Some
problems require investigation for an underlying medical or psychological problem(s). Ideally, these
three actions make a logical sequence with which to handle nutritional problems. However, specific
protocols need to be developed by each provider based on the resources available in the local
community. The table on the next page, “Criteria for Identifying Nutritional Problems Requiring
Follow-Up or Referral,” suggests levels at which some action should be taken.
12/82
CRITERIA FOR IDENTIFYING NUTRITI
TABLE 1
ONAL PROBLEMS REQUIRING FOLLOW-UP OR REFERRAL
CONDITION
SCREENING METHOD
CRITERIA FOR NUTRITIONAL EDUCATION
AND EVALUATION
CRITERIA FOR REFERRAL,
DIAGNOSIS AND TREATMENT
Delayed Growth Height for Age and Weight for Height
plotted on the NCHS growth chart.
Between 5th and 10th percentile with height and welght
of parents considered.
e Below 5th percentile, consider height of parents.
e Lower percentile than earlier measurements.
e Any major change In percentiles.
Underweight infant and Prepubertal Children:
weight for Height plotted on the NCHS
growth chart.
Adolescents:
Refer to Guidelines for Body Weight In the
appendix.
infant and Prepubertal Children:
Between 5th and 25th percentile, dletary guidance
is Indicated.
Adolescents:
If approaching the criteria tor referral, educate on danger
of extreme thinness.
infant and Prepubertal Children:
e Below 5th percentile.
e Lower percentile than earlier measurements.
e Any major change In percentiles.
Adolescents:
e 10% below the average value of the Weight for Height In @
table in the appendix, adjusted for age (subtract 1 pound fo
each year below age 25).
Overweight Infant and Prepubertal Children:
weight for Height plotted on the NCHS
growth chart.
Adolescents:
Refer to Guidelines for Body Weight In the
appendix.
infant and Prepubertal Children:
If the child Is between 75th and 95th percentile, educa-
tion about prevention of obesity may be Indicated.
Adolescents:
10% above the average value of the Weight for Height In
the table In the appendix, adjusted for age.
infant and Prepubertal Chlidren:
e Above the 95th percentile.
e Higher percentlie than earlier measurements.
e Any major change In percentiles.
Adolescents:
e 20% above the average value of the Weight for Height In the
table In the appendix, adjusted for age (subtract 1 pound for
each year below age 25).
Anemia Hemoglobin Concentration* gm/di
Hematocrit®*
Age (Year) Sex
2—10 Both
10—14 Both
14+ Male
14+ Female
12—10 Both
10-14 Both
14+ Male
14+ Female
Education concerning food rich In Iron, protein, and
vitamin C should be given at these feveis to bulid iron
stores.
Age (Year) Sex
y2—10 Both
10-14 Both
14+ Male
14+ Female
2—10 Both
10-14 Both
14+ Male
14+ Female @
Inadequate Food
Intake Dietary Screening Tool Diet Inadequate In one of the food groups on CHDP
dletary form. e Diet Inadequate In two or more food groups on the CHDP form.
e Frequent consumption of high sugar snacks coupled with identl-
fled dental problems.
e Regular pattern of Intake of non-food Items.
* adjust the hemoglobi
Less than 800 meters (2,624 feet) above sea level—no adjustment.
800—1300 meters (2,624 feet—4,265 feet) above sea level—add 0.5 gm hemoglobin and 2 hematocrit points.
Over 1300 meters (4,265 feet) above sea level—add 1.0 gm hemoglobin and 3.0 hematocrit points.
12/82
n and hematocrit values at high altitudes as follows:
DEVELOPMENTAL HISTORY AND ASSESSMENT
A developmental assessment examines the developmental process of persons from birth to young
adulthood. The purpose is to review the person’s developmental achievement and compare this
achievement with the developmental achievement of others of similar age and background in order
to identify possible developmental delays or other adverse conditions. The developmental history
includes information which, when integrated with information from the other parts of the health
history and from the physical examination, will enable the screening provider to make a screening
judgement relative to whether or not further developmental assessment or follow-up seems indi-
cated.
Sources of information about the child’s development include:
1. Observing the behavior of and talking with the child or adolescent, and
2. Talking with other persons who have knowledge of the child’s development or who are
familiar with the child’s usual functioning. Other persons include parents, teachers, health
professionals, and institutional officials (in the case of institutionalized children).
Information provided by the parent or other person acting as the child's parent is particularly im-
portant. This is especially true when there are ethnic, cultural, language, geographical, or other
differences between the child and the screener. The parent usually has the most complete knowl-
edge of the child and is better able to comment on his growth and development especially in
comparison with other children who may be in the family.
No single approach to the developmental assessment is suggested because no instruments or tests are
applicable to all cultural and geographical groups. It is important that the child’s physical and
developmental histories be integratively assessed at each CHDP health assessment, that the focus
and content of the assessment relate to the person’s age, that the developmental assessment be
culturally sensitive and valid, and that the assessment not be stigmauzing.
The CHDP program differentiates three levels of developmental assessment. Level 1 is the initial
screen; Level 2 is a more definitive evaluation; Level 3 is diagnosis and treatment.®
Level 1
This initial assessment is done within the context of the complete CHDP history and physical
examination, and is included in the fee for that service. The purpose of this level of developmental
assessment is to take into consideration information from the health and developmental history, the
physical examination, and the person or parent. On the basis of warning signs and other clues which
this information might provide, a screening judgment (not a diagnosis) is then made relative to
whether or not possible developmental problems may exist and referral for a more detailed evalua-
tion is indicated.
The provider who performs the Level 1 developmental assessment may make the referral for a Level
2 developmental assessment to himself or herself if the provider is qualified to conduct develop-
mental screening tests or otherwise evaluate developmental achievement. Local CHDP programs
may also be contacted for the developmental assessment resources including private practitioners,
health department clinics, and school related psychological and psychometric services.
Referral and Follow-Up
Persons should be referred for diagnosis and treatment if such referral is indicated by the first or
second levels of the developmental assessment.
*For further information, refer to Level 2 and Level 3 on page 14.
Several elements should be considered before referring. The absence of any single developmental
factor should not automatcally, in itself, result in a referral. The overall picture should be assessed:
the history, physical, and the situational context of the assessment itself. If the person is already in,
or has access to, ongoing health care, a medical note in the record to observe questionable areas may
be more advisable than a referral; active, ongoing care may be preferable to referral, but a referral
should be made, if warranted, rather than doing nothing.
The following examples illustrate stages of age-related development and are intended to serve as a
history of development which may be used as part of a Level } assessment. The examples do not
represent average development for the ages indicated but, rather, show those developmental stages
which have usually begun to emerge, are fully manifest, or are somewhere in between, in almost all
persons (95th percentile) by the age indicated. It may, therefore, be advisable to additionally
explore the developmental stages listed under ages which are younger and older than the age of the
person being screened.
The examples shown for the first two age categories (‘“‘under 1 month” and “1-2 months”) repre-
sent normal reactons of infancy. The examples shown for the last age category (“18 through
20 years”) represent social-emotional development. The examples shown for the intervening ages
(3 months through 17 years) represent six domains of development: gross motor, fine motor, self-
help skills, socialemotional, cognitive, and language (receptive and expressive). Due to the extreme
importance of detecting hearing problems early, “hearing” is shown as an additional category for
each age grouping through the first year of life.
Under 1 Month of Age
Sucks bottle, breast, or a person’s finger.
Grasps a person’s finger when placed in baby’s palm.
Turns head in direction of stroked cheek.
Moves arms and legs equally while on back or being held.
Hearing is evident if a child demonstrates a blinking reflex, startle reflex, and arousal (observable
generalized body movement) to an intense auditory signal.
1-2 Months of Age
Looks at person’s face when lying on back and face-to-face with person.
Lifts head when placed on stomach.
Follows, with eyes and/or head, a slowly moving object about eight inches from baby’s face.
Hearing is evident if a child demonstrates a blinking reflex, startle reflex and arousal (observable
generalized body movement) to an intense auditory signal.
3 Months — 17 Years
Refer to the tables on the following pages for the developmental stages for these age groups.
18 Through 20 Years
Is developing strong positive relationships with males and females.
Can think of, or has wishes about, independence and life plan.
Does not have erratic mood changes.
Engages in recreational activities.
11
3 MONTHS 6 MONTHS 9 MONTHS 12 MONTHS
GROSS MOTOR
DEVELOPMENT
Holds head by self
when placed in sitting
position.
Attempts to roll over. Sits without support. Pulls to a stand, and
stands and walks with
support.
FINE MOTOR
DEVELOPMENT
Retains small object
like a ring in hand after
it is placed there.
Grasps or reaches for
objects.
Reaches for object with
one hand more often
than with two hands,
and transfers objects
from one hand to an-
other.
Uses thumb and fingers
for grasping a small
object (like a sugar
cube) without scooping
it into the palm with
the fingers.
SELF-HELP
SKILLS
DEVELOPMENT
Gross and fine motor skill items ‘‘above’’
are applicable for first nine months.
Drinks from cup or
glass with assistance.
SOCIAL.
EMOTIONAL
DEVELOPMENT
-Smiles. Reacts socially by smil-
ing in response to some-
one’s smile.
Cries or is fearful in
presence of strangers.
Plays peek-a-boo, patty-
cake, or waves bye-bye
when someone models
these games.
COGNITIVE
DEVELOPMENT
Eyes track a small, round
object (not a pencil) as
it is moved back and
forth about 8 inches
from child's face.
Reacts (e.g., smile van-
ishes, eyes follow, activ-
ity level changes) when
examiner's face is quick-
ly moved out of range
of infant's vision.
Turns head when object
infant is attending to
falls from table edge to
floor naisiy (e.g, spoon).
Looks for fallen spoon
LANGUAGE
DEVELOPMENT
Expressive: coos or
makes sounds. Recep-
tive: responds (e.g, head
turning, changing facial
expression, ceasing ac-
tivity) when person
speaks outside infant's
range of vision.
Expressive: vocalizes two
different sounds. Recep-
tive: no item.
Expressive: vocalizes
when person talks or
smiles at infant. Recep-
tive: no item,
(as described in pre-
vious item).
Expressive: vocalizes
four different syllables
(e.g., da, ma, erg, goo,
ah). Receptive: recog
nizes mother’s voice
(e.g, has change in
activity, facial expres-
sion, attention, etc.).
HEARING"
Hearing is evident if a
child demonstrates a
blinking reflex, startle
reflex and arousal to
- hm am -- - ta Hearing is evident if a
child turns toward
sound with eyes and
head movement. Hearing is evident if a
child turns toward
sound with eyes and
head movement. Hearing is evident if a
child demonstrates an
understanding of some
words by appropriate
18 MONTHS 2 YEARS
| 3 YEARS 4-5 YEARS
GROSS MOTOR Walks without support. Stands on one foot |
1
Walks a few steps on Hops on one foot.
DEVELOPMENT with slight support. tiptoe along a straight
line (e.g., chalk line).
(Can go off line a
little.) Can ride tri-
cycle if regularly
available.
FINE MOTOR Brings hands together | Attempts to turn pages | Scribbles with pen or | Copies circle by five
DEVELOPMENT at midline of the body | of a book or magazine | crayon. ! years.
without physical assis-| on own initiative or
tance when initiating | after demonstration.
pattycake. |
|
ji
SELF-HELP Feeds self with hands. Uses spoon and cup. Daytime toilet trained. | Toilets self without
SKILLS help.
DEVELOPMENT
SOCIAL- Plays with toys appro- | Asserts feelings with | Beginning to play with | Plays and shares with
EMOTIONAL priately, e.g., pulls a | negative behavior, e.g., | other children and | other children. Can sit
DEVELOPMENT pull-toy; cuddles doll. tantrums, kicking breath | accept strangers. Can be | still.
holding, running away. satisfied when angered
or upset.
COGNITIVE Looks at pictures in| Responds by pointing, | Discriminates 2 of 3 | Recognizes colors, com-
DEVELOPMENT book or magazine. touching, or looking | objects by giving | mon shapes (circle,
when asked to indicate | requested object from | square, triangle), and
a familiar object, e.g., | an array of 3 familiar | counts to 10 by rote.
shoes, own toy, cloth- | objects. (Can give 2 of
ing. (No gestures used.) | the same 3 objects.)
LANGUAGE Expressive: says mama, | Expressive: initiates | Expressive: speaks | Expressive: speaks
DEVELOPMENT dada, or other culturally | simple words (like go, | appropriately in phrases | appropriately in phrases
appropriate words. | kitty) or sounds. Recep- | which family canunder- | understood by others.
Receptive: indicates | tive: after given a | stand. Receptive: gives | Receptive: indicates
answer (by looking, | block, follows 2 out of | only 1 block from 12 | knowledge of preposi-
pointing) to one simple | 4 instructions without | when requested to give | tions by placing object
question accompanied | gestures, e.g., put on | just 1. as requested, e.qg., under,
by gestures. table, put on chair, give on, behind.
to mama, give to me.
12/82 Page 2 of 3
6-11 YEARS 12-17 YEARS
GROSS MOTOR
DEVELOPMENT
Can ride bike, skip, play ball, swim,
climb, dance, or engage in other
activities requiring motor skills.
Same as previous age, but focus-
ing on and developing skills in motor
activities of interest.
FINE MOTOR
DEVELOPMENT
Cuts, pastes, and draws pictures. Has eye-hand coordination ability to
do any fine motor skill of interest.
SELF-HELP SKILLS
DEVELOPMENT
Bathes self unaided by end of period. Is able to care for self or others.
SOCIAL-EMOTIONAL
DEVELOPMENT
Relates to other children and partici-
pates in group activities.
Has friends outside family and gets
along with adults.
COGNITIVE
DEVELOPMENT
School performance (e.g., reading,
writing, spelling, etc.) is adequate.
School performance (e.g., reading,
writing, spelling, etc.) is adequate.
LANGUAGE
DEVELOPMENT Expressive: names three animals in one
minute when asked, “Tell me all the
animals you can think of.” Receptive:
follows directional commands such as
“Put left hand on left knee’ in one
attempt. Expressive: initiates communication
and expresses self appropriately in
different settings.
13
Level 2
The purpose of Level 2 is to provide a more detailed evaluation of suspected developmental condi-
tions. Because Level 2 is not part of the immediate CHDP screen, more attention may be focused to
evaluating the patient’s level of development. One or more of many available, more structured,
standardized developmental tools or procedures—relevant to the age-related dimensions outlined in
the developmental history above—can be used. Level 2 procedures are still relatively brief, economi-
cal, make minimal use of professional time and provide a more definitive evaluation than does
Level 1. It may indicate that no further follow-up is needed, or that a referral for diagnosis or treat-
ment is needed. Level 2 assessments are reimbursable by Medi-Cal.
Level 3
This level of developmental assessment provides for an in-depth evaluation by a psychologist,
psychiatrist, or multidiciplinary team which may include such disciplines as social workers, and
speech and hearing specialists. Private practitioners, California Children Services, regional centers,
community mental health clinics, university affiliated projects, reading clinics, and the Easter Seal
Society are examples of local referral sources. Access to a Level 3 developmental assessment is by a
referral from a Level 2 assessment. The purpose of a Level 3 developmental assessment is to provide
a diagnosis and, if needed, the initiation of or referral to treatment.
HEALTH EDUCATION
Health education is a required, integral part of health screening and evaluation services. The purpose
of health education is to promote optimal family health by offering counseling about the health
needs of the child or youth. Health education in the clinical setting is based upon the needs of the
individual or family. Persons are encouraged to make decisions which will enhance their own and
family’s well being.
Health Education Process
During each examination, the following activities comprise the health education process:
1. Identification and discussion of patient health concerns and health risks, based upon age
and health status;
2. Mutual agreement with patient on health education objectives;
3. Identification of available health education resources (parenting classes, nutrition coun-
seling, audio-visual materials, printed materials, etc.) if appropriate;
4. Explanation of the health assessment results, the need (if necessary) for referral(s), and
preparation for the referral visit; and
5. Evaluation at a later visit, as to whether the previously identified health behaviors have
been adopted.
Health Education Topics
Listed on pages 15—19 are some suggested health education topics by age, based upon health risks
and common patient concerns. This material may be used as a discussion guide with parents/
patients on health education subjects of importance or concern.
Resources
Health education pamphlets and/or consultation services may be available to providers from local
CHDP programs on subjects such as nutrition, safety education, parenting, dental health, etc.
12/82
SUGGESTED HEALTH EDUCATION TOPICS
-
- EE IL a ee
BIRTH—2 MONTHS
3—4 MONTHS
UBJECT
ENT Infant:
Reinforce previous concepts: Ages Birth—2 Months.
ICERNS ® Each Is unique: some need more attention; some need less.
> OPPOR- ® all need constant, consistent care to develop trust. Infant:
IITIES ® Small babies cannot be spolled by attention. e Cries have different meanings: may be lonely, need to turn over, etc.
1 e Cuddle and talk with; when fussy, rock, play music, and/or carry around, e Enjoys seeing many things and being with family.
LENTING ® Alternate on stomach and back. e Bath time is good for exercise, play, and talk.
e Place moblle and toys nearby.
Parents:
Parents:
e Enjoy unique growth pattern and personality of baby.
e May feel overwhelmed and tired. Mother may feel blue or depressed. e May be concerned about baby’s development.
e Need support from family.
e May be tired from constant caring for baby.
eo Mother needs time for herself away from baby. e May be concerned about relationship with spouse.
e Father should be encouraged to assume responsibility for care of infant.
rRITION General Discussion :
Reinforce previous concepts: Ages Birth—2 Months.
e Explanation of a normal growth pattern.
e Adequate amounts of breast milk or infant formula wlll support growth until 6 months of General Discussion :
age,
e As Infant continues to grow, more breast milk or formula will need to be consumed.
e Infant's digestive tract is not ready for solid foods until 4—6 months.
e Feeding method should be compatible with the family’s lifestyle.
e Use only breast milk, formula, or unsweetened water.
Breast-feeding:
e Breast-feeding Is nutritionally preferable through the first year of life.
e Adequate diet with sufficient flulds and rest for the mother is important.
e Infant may need to nurse more frequently than a bottle-fed baby.
e Position and technique of nursing is important.
Formula Feeding:
e {ron-fortifled formula is usually preferred.
e Instructions for preparation of formula need to be followed.
e|f a clean method of preparation Is used, sterilization Is not necessary.
e Baby should be held while being fed.
Women, Infants, and Children (WIC) Nutrition Program :
e Infants and/or breast-feeding mothers of low Income famiiles who are at nutritional risk
should be referred to WIC (see Appendix E for criteria).
JTAL Mouth:
Reinforce previous concepts: Ages Birth—2 Months.
RE e Clean chlid’s gums with dampened gauze or cotton swab when bathing baby.
Mouth:
Fluoride:
e Thumb and/or pacifier sucking is OK. Use recommended type of pacifier.
e |f community water supply Is not fluoridated, determine If fluoride should be given.
(Local health departments have specific fluoride recommendations.)
e Breast-fed bables need supplemental fluoride from birth.
\LTH Accidents:
Relnforce previous concepts: Ages Birth—2 Months.
KS e Falls: Do not leave alone on bed or changing table. ® Car Injurles: Use dynamically crash-tested car safety seat.
e Drowning: Hold infant firmly while bathing.
Medical Care:
e Health Checkups: Obtain regular health checkups and Immunizations. Consult doctor
early about an lliness.
e Medical Emergencles: Locate nearest emergency room; keep phone number and address
of emergency room and doctor near phone.
Environment:
e Select crib painted with nonlead-based paint and with slats no more than 2-3/8 Inches
apart.
¢ Smoke Detectors: Place smoke detectors in bedroom haliway.
Environment:
e Unsafe Objects and Toys: Destroy plastic bags; keep safety pins closed.
e Polsonings: Label medicines and poisons.
e Burns: Keep baby away from stove. Don’t hold baby while drinking hot liquids.
Page 1 of 5
SUGGESTED HEALTH EDUCATION 10PICS
AGE
SUBJECT 5—6 MONTHS
7—9 MONTHS
10—12 MONTHS
PARENT by :
Reinforce previous concepts: Ages 5—6 Months. Reinforce previous concepts: Ages 5—6 Months and 7-9
CONCERNS e Continue to anticipate and consistently meet needs.
Months.
AND e Talk, play, exercise, and love while providing care. Baby :
OPPOR- e Enjoys demanding attention. e Although wary of strangers, encourage parents to let baby Baby:
TUNITIES e Will begin to explore body and discover ears, feet, and meet ‘new’ persons. e Crawling and walking help development, but needs constant
FOR enitals.
e Enjoys pat-a-cake and making noise with pots and pans, etc. supervision; put In playpen or high chalr when parent Is
PARENTING e Playing *peek-a-boo’’; l.e., disappearing and reappearing e Baby should not always be confined during waking hours; busy.
will help to develop trust. encourage parents to let baby crawl and pull self up to e Enjoys large objects with different textures and containers
standing position.
in which to put things.
Parents:
e Worry about protectin oaby,
Parents:
e Mother needs time for herself each day away from baby.
e Concerned about spoiling baby and how to teach baby not
eo Father should be encouraged to take responsibility for care
to touch certain objects.
of baby.
e Shifting role from protector to protector-teacher.
NUTRITION General Discussion:
Reinforce previous concepts: Ages 5—6 Months. Reinforce previous concepts: Ages 5—6 Months and 7—9
e Explanation of a normal growth pattern. > Months.
e Adequate amounts of breast milk or Infant formula will Formula Feeding:
support growth until 6 months of age. e If mother uses cow's milk, be sure it Is not low-fat or
e Use only breast milk, formula, or unsweetened water. nonfat milk as they cannot adequately support growth.
e Do not force foods. Make mealtime a pleasant time. e Limit amount to 3—4 cups per day.
e Discourage use of sugar and salt. :
Breast-feeding: Solid foods
° ihe hol 8 Is nutritionally preferable through the first 8 Ha og a variety of soft table foods including cereal and
year. *®
e Adequate diet, fluids, and rest for the mother are impor- Fricoutage BaD ota ie: finder foods sc" a3, toast
tant. e Avold raw vegetables, nuts, and grains which can choke
Formula feeding; ‘ young children.
e |ron-fortified formula Is usually pre erred. So . .
.
und Feeding Practices :
}i 3 Sleah, method of preparation Is used, sterilization Is not | (Tp, ants, Including father, are models for child's eating
e Feeding Is the best time to cuddle baby. habits,
:
e Baby's learning to eat Is a messy experience but important
Solid Foods:
for his/her development.
® Place food on back of tongue with small spoon.
5 months—single grain Infant cereal strained or blended
vegetables and fruit (starting with cereal).
6 months—strained meat, egg yolk, dairy foods, beans.
e Use 5—7-day Intervals between Introduction of different
foods to determine allergles.
e Never add solid food to bottle.
Women, Infants, and Children (WIC) Nutrition Program :
e infanfs and/or breast-feeding mothers of low Income
families who are at nutritional risk should be referred to
WIC (see Appendix E for criteria).
DENTAL Teeth:
Reinforce previous concepts: Ages 5—6 Months. Reinforce previous concepts: Ages 5—6 Months and 7—9
CARE eo When teeth erupt, clean teeth, gums, and tongue daily with ; : Months.
dampened gauze or cotton swab. Prevention of Dental Disease: ; :
e Do not glve sweets; give soft fresh fruit or baby blscults for Prevention of Dental Disease:
Fluoride:
snacks.
e Only give sweets when teeth will be cleaned after eating.
e Continue to give fluoride drops If water Is not fluoridated | © If giving bottle in bed cannot be avolded, use only water. e Give baby own toothbrush and let baby imitate teeth
or baby Is breast-fed.
brushing.
Teething:
e Relleve discomfort by rubbing gums and/or offering clean
teething ring.
HEALTH Accidents:
Reinforce previous concepts: Ages 5—6 Months. Reinforce previous concepts: Ages 5—6 Months.
RISKS e Falls: Do not leave alone on bed or changing table. Place
12/82
stalrway guards at top and bottom of stairs.
e Car Injurfes: Use dynamically crash-tested car safety seat.
LJ Drowning: Watch Infant carefully when in tub or near
water.
Medical Care:
e Health Checkups: Obtain regular health checkups and
immunizations. Consult doctor early about an lliness.
e Medical Emergencies: Locate nearest emergency room
keep phone number and address of emergency room and
doctor near phone,
Environment:
e Use crib painted with nonlead-based paint and with slats no
more than 2-3/8 inches apart.
e Smoke Detector: Place smoke detector in bedroom hall-
way.
e Unsafe Objects and Toys: Destroy plastic bags; keep safety
ins closed; toys should be nontoxic, not sharp, flame resis-
ant, and have no small parts; cover electrical outlets.
Poisonings: Label medicines and polsons; keep from child’s
reach; keep 1 oz. Syrup of Ipecac avallable to use If doctor
orders.
Burns: Don't hold baby while drinking hot liquids; turn pot handles on stove inward,
Pu_ £5
I
(0
SUGGESTED HEAL. .OUCATION TOPICS
AGE
UBJECT 13—17 MONTHS 18—23 MONTHS 2 YEARS
NT ild: Relnforce previous concepts: Ages 13—17 Months. Reinforce previous concepts: Ages 13—17 and 18-23
"ERNS e Begins to develop sense of independence when trust Is satis- Child Months.
fled. id:
'R- e Closely supervise play so trial and error learning can take |e May have temper tantrums. Child:
TIES place. e Encourage play with other toddlers. e “Terrible Twos''—ormal for child to be negative.
« Needs affection: kiss and hug many times each day. e Self-discipline Is developed through a dally routine for eat- | e wants to do everything but can't.
NTING e Continues to walk, explore, and become fatigued. ing, bathing, sleeping, etc. e Cannot identify safe from unsafe.
e May have negative moods.
eo May create stress at meals, bedtime, etc.
e Explores genitals and other body parts. Parents:
e May worry about child's safety. Parents:
Parents: e Expectations of child may be too high because child walks e May experience frustration and anger toward child and
e May need to discuss with other familly members differences and talks. gullt about these feelings.
of opinlons about raising children.
e May have questions about when to begin tollet training;
suggest beginning at 18—23 months of age.
e May have need to spend time together away from child. en Be el Fa et a a a a ros SSE oh Ton
UTION General Discussion: Reinforce previous concepts: Ages 13—17 Months. Reinforce previous concepts: Ages 13—17 Months.
e As baby's rate of growth slows down, the amount of food
:
required decreases.
ound Feeding Practices:
e Feeding problems may arise if parents force food. Mealtime e Child needs 3 meals plus 2 nutritious snacks a day.
should be enjoyable.
e Child needs 2—3 cups of milk, whole grain and enriched
e Parents set an example for child's eating habits.
cereal, a variety of fruits and vegetables, meat, beans, tish,
e Food should not be used as a reward or as a disciplinary
poultry, or peanut butter.
measure.
e Offer a cholce between similar types of foods.
e Encourage self-feeding.
e Limit salt and sugar intake.
: 4
e Avold raw vegetables, nuts, and grains which can choke
Milk and Fluids:
young children.
e Breast-feeding Is nutritionally sound if mother Is not preg- ® Foods are consumed both at home and In day care settings
nant and the baby learns to eat a variety of other foods by so parents need to assure the availability of nutritious foods
himself.
at home and away.
e Wean from breast or bottle to spout cup.
e Foods should not be used as a reward or punishment.
e Decrease milk to 2—3 cups per day since excess milk ma
interfere with Intake of solid food and lead to Iron defici-
ancy.
e Encourage water or fruit juice; avoid soda pop, other sweet
drinks.
Solid Foods:
e Child needs 3 meals plus 2 nutritious snacks a day.
e Encourage a variety of table foods.
e Offer cholces between similar types of foods (e.g., between
banana and apple sauce.
e Avold candy, sweetened cereals, and sweet baked products.
Women, Infants, and Children (WIC) Nutrition Program:
e Children of low income families who are at nutritional risk
should be referred to WIC (see Appendix E for criteria).
gon
TAL Teeth: Reinforce previous concepts: Ages 13—17 Months. Reinforce previous concepts: Ages 13—17 and 18-23
= e Continue to brush teeth, gums, and tongue using small ; : Months.
amount of fluoride toothpaste. Prevention of Dental Disease:
: e Parents should understand the value of primary teeth In | Prevention of Dental Disease:
Fluoride: speech development, eating habits, and permanent teeth e Parents should demonstrate to child proper method of cir-
e Continue fluoride drops If water Is not fluoridated. spacing. cular brushing and brush teeth, gums, and tongue after
e Child cannot successfully brush own teeth regardless of meals.
Parents: supervision, e Parents may begin to floss child's teeth dally.
e Parents should understand the Importance of practicing e By age 3 years, some dentists recommend the application of
good dental habits since thelr example will influence the sealant on teeth to prevent cavities.
child's behavior.
LSE i en Len TERS ai DRO Gast ba gta Ce
«TH Accidents: Reinforce previous concepts: Ages 13—17 Months. Reinforce previous concepts: Ages 13—17 Months.
S e Falls: Do not leave alone on bed or changing table. Use
stairway guards at top and bottom of stairs.
e Car Injuries: Use dynamically crash-tested car safety seat.
e Drowning: Watch Infant carefully when In tub or near
water.
Medical Care:
Health Checkups: Obtain regular health checkups and
Immunizations. Consult doctor early about an lliness.
Medical Emergencies: Locate nearest emergency room;
keep phone number and address of emergency room and
doctor near phone.
Environment:
e Crib: Use crib painted with nonlead-based paint and with
slats no more than 2-3/8 Inches apart.
e Smoke Detectors: Place smoke detector In bedroom hall-
way.
e Unsafe Objects and Toys: Destroy plastic bags; keep safety
ins closed; toys should be nontoxic, not sharp, flame resis-
ant, and have no small parts; cover electrical outlets.
e Poisonings: Label medicines and poisons; keep from child's
feach; keep 1 oz. Syrup of Ipecac avallable to use If doctor
orders.
e Burns: Keep hot substances and matches out of child's
reach; turn pot handies on stove inward, turn hot water
heater control to 120°.
Exercise:
e Dally routine should Include outdoor exercise.
~ SUGGESTED HEALTH EDUCATION TOPICS
SUBJECT
AGE
3 YEARS 4—5 YEARS 6—8 YEARS
PARENT
CONCERNS
AND
OPPOR-
TUNITIES
FOR
PARENTING
Child:
e Will copy parents and other adults.
e May like to help with “housework, etc.
e Can wash face and help get dressed.
e Giving choices helps make discipline easler (l.e., which
cereal to eat, shirt to wear, etc.).
eo Needs lots of love and attention.
Parents:
e Concerned about providing a safe environment and keeping
cy with an active chlid.
e May be overprotective.
Reinforce previous concepts: Age 3 Years.
Child :
e Less dependent upon adult; may be aggressive, talk back, or
swear; may possibly wet bed.
e Masturbation and questions about sex are natural.
e Forms friendships.
e Understands concepts like ‘tomorrow (beginning process
of reason).
Parents:
e A good way to answer questions about sex:
3} Find out what child thinks and
2) Give honest and simple Information.
e May be anxious about child's readiness for school; helpful
to take child to visit school.
eo May need reassurance that chlidren adjust well.
e Teach child to ask parent's permission before accompany-
Ing anyone.
Reinforce previous concepts: Ages 3 and 4—5 Years.
Child :
LJ Sirowing Independence.
® Physically very active; may swim, play ball, ride bike, etc.
e Usually boys play with boys; girls with girls.
e Develops close friendships.
Parents:
e May be concerned about Injuries and Increasing Independ-
ence.
NUTRITION General Discussion:
e As child's rate of growth slows down kK may want less food.
e Parents set an example for child's eating habits.
e Mealtime should be an enjoyable family experience.
e Food should not be used as a reward or as a disciplinary
measure.
Milk and Fluids:
e Decrease milk to 2—3 cups per day, since excess milk fay
interfere with Intake of solid food and lead to iron deficl-
ency.
e Encourage water or frult julce; avold soda pop, other sweet
drinks.
Solid Foods:
e Encourage a variety of table foods.
e Offer cholces between similar types of foods (e.g., between
banana and apple sauce, etc.).
e Avoid candy, sweetened cereals, and sweet baked products.
Women, Infants, and Children (WIC) Nutrition Program:
e Children of low income famiiles who are at nutr tional risk
should be referred to WIC (see Appendix E for criteria).
Reinforce previous concepts: Age 3 Years.
Sound Feeding Practices :
e Help child take time for breakfast.
wicC:
e Children 5 years and older are not eligible for WIC (see
Appendix E).
Sound Feeding Practices:
eo Milk consumption may Increase to 4 cups per day.
e As child has more Independence, give more assistance
choosing nutritious food for meals and snacks.
wicC:
e Children 5 years and older are not eligible for WIC (see
Appendix E).
DENTAL
CARE
Prevention of Dental Disease:
e Parents should demonstrate and supervise correct brushing
and flossing technique on child's teeth, gums, and tongue
after each meal.
e Use fluoride tooth paste.
e Sweets contribute to tooth decay. Limit snacks to healthful
foods such as fruits, vegetables, and popcorn.
e See dentist regularly (at least once a year).
e |f pain or bleeding occurs, consult dentist Immediately.
Reinforce previous concepts: Age 3 Years.
Prevention of Dental Disease:
e Disclosing tablets or solution may be used occasionally to
check for thoroughness of brushing and flossing.
* Avoly use of presweetened cereals, candy, and other sugary
snacks.
e Bad breath can be controlled with removal of plaque,
proper brushing, flossing, and regular dental visits. Mouth
washes are not necessary.
Reinforce previous concepts: Ages 3 and 4—5 Years.
Prevention of Dental Disease:
e Child can brush and floss although adult demonstration and
reminders are necessary.
e Begin to emphasize child's own responsibility for dally
dental care.
HEALTH
RISKS
Accidents:
e Car Injuries: Use dynamically crash-tested car safet
e Drowning: Watch child when near water; begin
water safety.
Medical Care:
e Health Checkups: Obtain regular health checkups and
immunizations. Consult doctor early about an lliness.
eo Medical Emergencies: Locate nearest emergency room;
keep phone number and address of emergency room and
doctor near phone.
seat.
o teach
Environment:
e Unsafe Objects and Toys: Destroy plastic bags; toys should
be nontoxic, not sharp, flame resistant, and have no small
parts; cover electrical outlets; turn hot water control to
120° or less.
Poisoning: Label medicines and polsons; keep from child’s
[each; keep 1 oz. Syrup of Ipecac available to use If doctor
orders.
Burns: Keep hot substances and matches from child's
reach; turn pot handles on stove inward.
Exercise: Child needs dally exercise.
e TV: Control TV viewing to appropriate programs.
Relnforce previous concepts: Age 3 Years.
Accidents:
e Car Injuries: Use seat belts regularly.
Environment:
eo Drowning: Teach child to swim.
e Tricycles/Bicycles: Teach child safe tricycle/bicycle riding
practices.
e Burns: Teach child never to play with matches.
Paae 4 of 5
Reinforce previous concepts: Age 3 Years.
Accidents:
e Skateboard
practices.
e Tooth fairy reward emphasizes value of teeth.
skateboarding Injuries: Teach child safe
SUGGESTED HEALTH EDUCATION TOPICS
AGE
9—12 YEARS 13—16 YEARS 17—20 YEARS
SUBJECT
PARENT Child: Reinforce previous concepts: Ages 9—12 Years. Reinforce previous concepts: Ages 9—12 and 1316 Years.
CONCERNS e industrious.
AND e Continued growth of Independence. Youth: Young Adult:
e Separate Identity achieved.
OPPOR-
TUNITIES
Peer pressure may stimulate Interest In smoking, drinking,
and other drugs.
Rapld growth and change may create confusion, depression,
anxlety, anger, and allenation from parents.
May be secretive, hostile, and negative.
Continued development and improvement of relationship
with parents.
Strives to be equal with parent—adult to aduit.
FOR
PARENTING Parents: e Need to prove individuality and Independence may lead to *
e May worry about child's fallure If something new Is tried risk-taking behavior. e Needs success In directing own life.
and limit activities for fear of Injury. e Needs parental respect. e Increased Independence and preparation for job, marriage,
e Changes In chlid occur rapidly; accept and give support.
and college.
eo Family projects/outings help maintain closeness of family Parents :
members. ® May worry about teen's Increasing sexual Interest, physlo- Parents:
e If questions about sex are not asked, initiate discussion, logical changes, emotional stress, and safety when dr ving | e Concern about youth's choice of friends, sexual partners,
especlally about menstruation, nocturnal ejaculation, etc. auto or motorcycle. glematule marriage, and drug usage.
eo Express affection often when opportunities arise. eo Need to discuss responsible sexual behavior. e Young people stiil enjoy family parties and outings and lke
e May be concerned about choice of friends, peer pressure, to help with civic Bik rg
drug usage, and group violence.
eo Aware of growing tension and lack of communication. Must
try to listen carefully to teen's feelings, accept and
acknowledge.
e Spend time with teen at home or on outings.
e Encourage exercise and participation In soclal activities
such as swimming, biking, hiking, etc.
NUTRITION Sound Feading Practices: Sound Feeding Practices: Reinforce previous concepts: Ages 13—16 Years.
oe Rapid growth at this age requires Increased amounts of Youth need to be Informed of good eating habits such as the
essential nutrients. following:
e¢ Encourage foods high In vitamins and minerals (particularly e Eat food from all food groups.
Iron and vitamin C). eo Eat something with protein In It for breakfast each morning
e Friends have an Increasingly strong Influence on eating even If there Is very little time.
habits. Therefore, children need guidance In order to make e Drink a sufficlent amount of liquids, especially water, every
wise cholces about their food. day; limit soft drinks.
e The dally diet should contain at least one raw vegetable and
one fruit.
e Avold too many fried, sweet, and salted foods.
DENTAL Prevention of Dental Disease: Reinforce previous concepts: Ages 9-12 Years. Reinforce previous concepts: Ages 9—12 and 13-16 Years.
CARE e Monitor dally brushing and flossing. : i ;
e Prepare nutritious meals and snacks. Popcorn, frult, raw Prevention of Dental Disease: Prevention of Dental Disease:
vegetables, and nuts are excellent afterschool snacks, e Increased tooth decay may occur during this period. e Each person responsible for own dental health.
e Some dentists recommend pit and fissure sealants as soon as e Emphasize importance of flossing, brushing, regular dental
12-year molars are In far enough. visits, and the avoldance of sweets, especially soft drinks,
candy, etc.
HEALTH Accidents: Reinforce previous concepts: Ages 9—12 Years. Reinforce previous concepts: Ages 9—12 and 13-16 Years.
RISKS e Car Injuries: Use seat belt or shoulder harness regularly.
e Drowning: Teach child to swim.
Madical Care:
® Health Checkups:
® Medical
® Sax Education:
Obtain regular health checkups and
immunizations. Consult doctor early about an liiness.
Emergencies: Locate nearest emergency room;
keep phone number and address of emergency room and
doctor near phone.
Parents should talk about responsible
sexual behavior and answer questions.
Environment:
eo Bicycle/Skateboard Safety: Teach child safe bicycle/
skateboarding practices.
e Burns: Teach child never to play with matches.
e TV: Guldance Is needed to control amount and quality of
viewing.
Accidents:
Car Injuries: Parents should stress the importance of seat
beits for the whole family.
Alcohol and Other Drugs:
Begin to teach responsible use of alcohol.
Don’t mix alcohol with other drugs.
Pregnant women should avoid alcohol and other drugs.
D:
Prevent VD by abstaining from sexual contact or by using
condoms.
Refer contacts early for dlagnosis and treatment.
Pregnancy :
amily planning services are avallable for sexually active
teens.
Personal and Social Adjustment:
e Counseling services are avallable to teens and youn adults
under stress. (Problems of teenage suicide, gang violence,
and homicide.)
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Page 5 of Bb
ADDITIONAL REQUIRED SCREENING PROCEDURES
VISION SCREENING
Screening shall include a history of medical or visual eye problems, any present signs or symptoms
relating to the eyes, an inspection of the external eye, neuromuscular coordination of the eyes,
evaluation of the retinal (red) reflex through the undilated pupil, and size and shape of the pupils
and their reaction to light and accommodation.
Infants
Vision and strabismus should be evaluated by checking the baby’s ability to follow a bright object
at near vision, Do this with both eyes open and with each eye covered.
Small Children (Ages 1-3 Years)
Vision, horizontal and vertical eye movements, and convergence should be evaluated by the child’s
ability to follow an object moving 12—15 inches from the face to a few inches from the nose.
Strabismus and suppression of vision may be suspected by monocular and alternating cover testing.
Children Age 4 and Over
Test as for small children plus the Snellen visual acuity test at a distance, real or optical, of 20 feet,
with results recorded in Snellen notation. The Worth Four-Dot Test (see Appendix F) may be used
to test for strabismus and suppression of vision.
Instrument testing may be substituted for evaluations of visual acuity, coordination, and suppres-
sion. Instruments which may be used include, but are not limited to, the Vision Tester, the Ortho-
Rater, the Ophthalmic Telebinocular, and the Screenscope.
Referral and Follow-Up
Conditions which should be treated or referred to a medical specialist if indicated include, but are
not limited to, bleeding, pus, lice, conjunctivitis, unequal pupils, cloudy media, and double vision.
Refer to an ophthalmologist or optometrist when any of the following conditions are noted:
1. A possible vision problem according to history or clinical observation.
2. Strabismus and/or suppression: Observed by cover test, Worth Four-Dot Test, or equiva-
lent test.
3. When using the Snellen visual acuity test:
a. For children under six years of age, a visual acuity of 20/50 or poorer.
b. For children six years of age or over, a visual acuity of 20/40 or poorer.
c. A difference of visual acuity between the eyes of two lines on the Snellen chart.
12/82
4. When using instrument testing:
Individuals should be referred according to the reference manuals for the Vision Tester,
Ortho-Rater, Ophthalmic Telebinocular, and Screenscope.
Reimbursement for Rechecks
rte sma a a: 3 ts
A provider will be reimbursed once for a screening recheck, done on a different day when the
accuracy of the initial test is questionable. The goal is to minimize unnecessary referrals and to
maximize appropriate referrals.
= — eee, ee rm —
HEARING SCREENING
It is extremely important to initiate hearing screening during infancy. Early detection and interven-
tion of a hearing impairment greatly reduces handicaps which result when hearing impairment inter-
feres with the development of speech and language. The following have been identified as risk
factors for hearing loss in infants:
Family historv of childhood deafness.
Maternal rubella during pregnancy, or other intrauterine viral infection.
Hvperbilirubinemia.
Maxillofacial anomalies.
Birth weight of 1,500 gm or less.
Severe anoxia.
Acidosis. N
o
w
h
w
Under 3 Years of Age
Children of this age should have an assessment of hearing by history and clinical observation during
the physical examination, noting behavior of the child in response to sound as well as noting prob-
lems in speech and language development. Special attention should be given to a history of fluctua-
ting middle-ear infections which can lead to developmental lags.
The following auditory milestones should be used only as a guide:
AUDITORY MILESTONES DURING INFANT'S FIRST 24 MONTHS
Age Auditory Milestone
1 to 2 months Startles at sound of loud, sudden noise.
2 months Listens to voices.
6 months Babbles to self (‘“baba,” “‘gaba,” “ma™).
Presents such consonant sounds as f, m, n, with mixed vowels.
Turns head toward sound source.
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22
Age Auditory Milestone
9 months Imitates speech sounds of other people.
Changes pitch of own voice.
Turns head toward sound source and locates source if at eye level or below.
12 months Uses one word correctly in addition to ‘“‘ma-ma’’ or “‘da-da.”
Stirs or wakes when sleeping quietly if there is a loud sound or someone nearby
talks.
15 months Uses three or four words (nouns) correctly in addition to ‘““ma-ma’”’ or ‘‘da-da.”
18 months Indicates wants by naming objects, such as cookie; typical vocabulary 50 words.
21 months Uses a combination of words and nonsense when talking.
24 months Occasionally uses a two-word or three-word sentence.
Refers to self by name; typical vocabulary 200+ words.
Source: Adapted from milestones compiled by Hearing and Speech Services, Handicapped Children’s Program, Colorado Depart-
ment of Health.
Three Years of Age
A pure tone audiometric hearing screening test (see Appendix G for qualifications and testing
standards) is recommended for these children if appropriate to the child’s behavior and ability to
cooperate. If the child is unable to cooperate, substitute the nonaudiometric methods used for the
earlier age groups.
Four Years of Age and Older
Children four years of age and older are to be given an individualized manually administered pure-
tone air conduction audiometric screening procedure.
Puretone audiometric screening tests are conducted at hearing levels (not to exceed 25 decibels) and
include frequencies 1,000, 2,000, and 4,000 Hz. Failure to respond to any frequency at any screen-
ing level constitutes a failure of the screening test and necessitates a rescreening which should take
place no sooner than two weeks. It is recommended that 3,000 Hz be used for increased reliability
and possible identification of subtle communicative problems among children.
Hearing screening rechecks may be done once for reimbursement if the test results were questionable.
Play audiometry is the recommended procedure for obtaining accurate responses from children
31:—6 years of age.
Referral and Follow-Up
A referral is made if any of the following conditions are found:
1. A possible hearing impairment according to history.
2. An infant with an absent blinking reflex, startle reflex, or arousal response.
3. Evidence of pathology, e.g., otitis media, chronic otitis media, or external otitis.
4. The pure tone audiometric screen reveals no respone in either ear to the screening level of
25 decibels at any one or more of the frequenaes.
TUBERCULIN TEST
A tuberculin test is administered by either an intracutaneous (Mantoux) test or a multipuncture
test. The Mantoux test is the preferred test, especially for high risk populations in which tubercu-
losis is found.
The health provider is responsible for reading and recording the results of the tests. The provider
should tell the parent or patient to report on the nature of the reaction. Parents/patients should be
encouraged to contact the provider whether or not they see a reaction.
The following represents the recommendations of the American Thoracic Society, The Medical
Section of the American Lung Association, and is endorsed and followed by the California Tubercu-
losis Controller’s Association and County Health Departments.
Intracutaneous Mantoux Test
The intracutaneous Mantoux test should be read within 48—72 hours after administration.
Interpretation of the results of the Mantoux test should be made according to the following:
1. A reaction of 0—4 mm of induration is negative and no follow-up is needed.
2. In cases of NO KNOWN CONTACT a reaction of 5 through 9 mm of induration is a
doubtful reaction and should be repeated at a different site.
3. In cases of KNOWN CONTACT a reaction of 5 through 9 mm of induration should be
interpreted as positive and referred for diagnosis and/or treatment.
4. A reaction of 10 mm or over is positive and should be referred for diagnosis and/or
treatment.
Multiple Puncture Test
Multiple puncture tests are not intended for diagnostic use but rather for an initial screening proce-
dure for groups of asymptomatic persons not exposed to a case of tuberculosis in whom only a
small proportion are expected to have tuberculous infection.
The multiple puncture test should be read within 48—72 hours after administration.
With the exception of persons with a vesicular reaction, which may be interpreted as a significant
(positive) reaction, those with any other reaction must be given a Mantoux test. Decisions concern-
ing management should be based on the reaction to the Mantoux test.
The local health department is an excellent resource for information about the diagnosis and treat-
ment of tuberculosis.
HEMATOCRIT OR HEMOGLOBIN
An accurate hematocrit or hemoglobin measurement is to be done.
The most common cause of anemia in this country is iron deficiency. Since there is an overlap
between the laboratory values for mild iron deficiency anemia and low normal hemoglobin and
Lematocrit values, there is often disagreement as to the best protocol to follow. Mild iron deficiency
23
anemia should respond within a few months to an increased intake of iron rich foods or a one-
month clinical trial of elemental iron. Clinical trials have shown the value of this treatment. Nutri-
tional education and diet change is preferable, however, since it encourages a real change in eating
habits by not providing an artificial crutch in the form of an iron supplement.
Referral and Follow-Up
The table below contains two blood levels at which follow-up is indicated. At the higher level,
nutritional education is recommended. At the lower level it is recommended that an iron supple-
ment medication be tried in addition to nutritional education. The exact procedures should be
based on the resources of the screening provider and the circumstances of the patient.
The age specific values for hematocrit and hemoglobin are:
CRITERIA FOR NUTRITIONAL CRITERIA FOR REFERRAL,
EDUCATION AND EVALUATION DIAGNOSIS, AND TREATMENT
Age (Year) Sex Below Age (Year) Sex Below
Hemoglobin® %2—10 Both 11.0 gm %—10 Both 10.0 gm
10-14 Both 12.0 gm 10-14 Both 11.0 gm
14+ Male 13.0 gm 14+ Male 12.0 gm
14+ Female 12.0 gm 14+ Female | 11.0 gm
Hematocrit® %-10 Both 340 % %—-10 Both 30.0 %
10-14 Both 37.0 % 10-14 Both 33.0 %
14+ Male 41.0 % 14+ Male 37.0 %
14+ Female 37.0 % 14+ Female | 33.0 %
Education concerning food rich in iron, protein,
and vitamin C should be given at these levels to
build iron stores.
* Adjust the hemoglobin and hematocrit values at high altitudes as follows:
e Less than 800 meters (2,624 feet) above sea level —no adjustment.
e 800-1300 meters (2,624—4 265 feet) above sea level —add 0.5 gm hemoglobin and 2 hematocrit points.
e Over 1300 meters (4 265 feet) above sea level —add 1.0 gm hemoglobin and 3 hematocrit points.
URINE DIPSTICK OR URINALYSIS
Screening for sugar, protein, and blood is to be done beginning at 4—5 years of age. It may be done
by either the dipstick method or by a complete urinalysis, according to the preference of the exam-
iner. It may be done at an earlier age if medically indicated.
Referral and Follow-Up
Any of the following positive results require further evaluation, diagnosis, or treatment:
1. 1+ sugar.
2. 2+ protein.
3. Unexplained blood.
PAPANICOLAU (PAP) SMEAR
A Papanicolau (Pap) smear is to be done beginning at 17 years, or younger if sexually active. High
tisk individuals for cancer-in-situ are those who (1) begin sexual activity in early teen years, and (2)
have multiple partners.
Sexually active individuals should be referred to family planning programs for appropriate services
including yearly Pap smears.
Referral and Follow-Up
A referral for further evaluation, diagnosis, or treatment is made when the smear is class Il or above.
SCREENING PROCEDURES WHEN MEDICALLY INDICATED
PHENYLKETONURIA (PKU)
The CHDP program will reimburse for Phenylketonuria testing done as a repeat test for infants up
to onc month of age who were tested in the hospital under 24 hours of age. Children who have not
been tested should be referred in accordance with the local health department protocol for new-
born screening for PKU, galactosemia, and congenital hypothyroidism.
Referral and Follow-Up
If the PKU test is presumptive positive, the child should be referred for diagnosis and treatment.
SICKLE CELL DETERMINATION
Black persons or persons whose ancestors came from areas near the Mediterranean Sea or the Indian
Ocean and have laboratory results showing anemia, i.e., hemoglobin of less than 11 grams or a
hematocrit of 34 percent or less, should be tested to determine their sickle cell status.
The cellulose acetate electrophoresis method must be used.
Request for Screening
If a program recipient who is not anemic and is a member of the target groups described above
requests a screening test for sickle cell anemia or trait, s/he should be referred to the nearest
community-based sickle cell screening program.
Referral and Follow-Up
When the test for sickle cell disease or trait is positive, it is recommended that counseling by a
physician or state-approved counselor be provided. Contact your local CHDP program for assistance
with referral if needed.
Counscling
The purpose of sickle cell counseling is to help the individual or family:
1 Understand the medical facts about the condition, including the diagnosis, the probable
cause of the condition. and the available management for the condition;
5 Understand the way heredity contributes to the condition, and the risk of recurrences in
specified blood relatives;
dl eva etal AF eRe vwrrencee nf the condition:
+. Choose the course of action which seems appropriate to them in view of their goals and act
in accordance with that decision; and
26
w
n
Make the best possible decision.
FREE ERYTHROCYTE PROTOPORPHYRIN (FEP)
BLOOD LEAD LEVEL
Children with pica behavior are candidates for lead poisoning because sources of lead are readily
available in our environment. Examples of environmental lead sources include paint chips (particu-
larly in old housing), colored magazine pages, contaminated soil, and clothing contaminated at lead
emitting work places. Certain folk medicines are an additional source of lead poisoning for children.
It is strongly recommended that if lead poisoning is suspected, a venous macro blood sample (5 ml.)
be drawn. If this is not possible, four capillary tubes of blood may be drawn: one for FEP, one for
blood lead, and two extra in case of clotting or breakage.
Testing consists of the following laboratory tests:
1. Free Erythrocyte protoporphyrin (FEP) — Only those with an FEP of 35 micrograms per
100 ml. of blood or greater should have a blood lead level.
2. Blood lead level — If the blood lead level is above 25 micrograms per 100 ml., a referral is
made tor diagnosis and treatment including confirmatory laboratory testing. Any child with
a confirmed blood level over 25 micrograms per 100 ml. should be referred to Public Health
Nursing and an environmental investigation should be initiated.
The laboratories conducting FEP or blood lead testing must participate in the State’s or CDC’s
proficiency testing program for CHDP to reimburse the tests. Prior approval must be obtained from
the State and the local CHDP directors only if routine testing is planned on all children screened.
Questions regarding laboratory analysis should be referred to:
Air and Industrial Hygiene Laboratory
Childhood Lead Program
2151 Berkeley Way
Berkeley, CA 94704
(415) 540-2469/ATSS 571-2469
Questions regarding medical consultation or environmental evaluation may be referred to:
Community Toxicology Unit
2151 Berkeley Way
Berkeley, CA 94704
(415) 540-3063/ATSS 571-3063
CCS covers diagnostic evaluations for possible lead poisoning without regard to income eligibility
and will provide for treatment costs, if required, for children whose family income is less than 300%
of the Federal poverty level.
GONORRHEA CULTURE
Cultures for gonorrhea may be done when deemed appropriate by the supervising physician on the
basis of the social/sexual history. The issue of appropriate contraceptives should be discussed at this
time and a referral made for family planning services if the person is sexually active.
Females
Cultures are taken from the endocervical canal in pubertal females, but may be taken from the
vagina in prepubertal females. Additional cultures may be taken from the anal canal and/or the oral
cavity. No more than three cultures, each of which must be taken from different sites, may be taken
for any one screen.
Males
Cultures are taken from the anterior urethral mucosa. Additional cultures may be taken from the
anal canal and/or the oral cavity. No more than three cultures, each of which must be taken from a
different site, may be taken for any one screen.
Referral and Follow-Up
Persons are referred for immediate evaluation, diagnosis, or treatment when the culture(s) for
Neisseria gonorrhoeae are positive.
Regulations of the California Department of Health Services require the reporting of gonorrhea to
the local health authority immediately.
LABORATORY TEST AND PROCEDURE RECHECKS
Rechecks of laboratory tests and procedures 04 through 30 (this excludes the health history and
physical examination) may be done once for reimbursement by the CHDP program when the
provider questions the accuracy of a laboratory test, or the tuberculin test, or when the patient has
failed the visual acuity test or audiometric test. Rechecks cannot be reimbursed by CHDP for any
other reason.
SCREENING PROCEDURES REQUIRING PRIOR APPROVAL
A community CHDP program may include health screening and evaluation procedures in addition
to those contained in these guidelines if such procedures are approved by the Department of Health
Services and the State Maternal, Child, and Adolescent Health Board.
IMMUNIZATIONS
Immunization status must be assessed and appropriate immunizations administered by the pro-
vider at the time of the health assessment unless medically contraindicated or refused by the parent.
It is the provider's responsibility to inform the person or parent/guardian of the benefits and risks
of the immunizing agents, to obtain evidence that an informed consent has been given, and to pro-
vide the patient with an immunization record showing for each vaccine dose given the type of
vaccine, date administered, and name of provider (physician or clinic).
Public clinics using Immunization Assistance Program (IAP) vaccines and giving OPV, DPT/Td/DT,
or MMR must use the risk/benefit forms the IAP provides. Private physicians using IAP vaccines
must sign a certification form saying they either will exercise individualized medical judgment
(regarding informed consent) or will use the “Important Information, Risk/Benefit” forms for each
patient.
The following immunization schedule, “GUIDE FOR USE OF SELECTED VACCINES AND
TOXOIDS,” from the Infectious Disease Section, California Department of Health Services, 1s
recommended.
27
State of California
Department of Health Services
This guide is intended to serve as a quic
Practices (ACIP) and the Report of the
committees for more detailed information on g
IMPORTANT: Avoid immunizing persons ill or febril
with the manufacturer. In addition, agents may contain substances to which patients may be sen
GUIDE FOR USE OF SELECTED VACCINES AND TOXOIDS
k reference for commonly employed immunization procedures. It is based o
Committee on Infectious Diseases 1977 (RED BOOK) of the American Aca
eneral considerations and specific applications of accepted immunization practices.
Infectious Disease Section
July, 1980
n recommendations made by the Public Health Service Advisory Committee on Immunization
demy of Pediatrics. Reference should be made to the complete published reports of these two
e in preceding 24 hours. Carefully read the product description and directions supplied with each immunizing agent as potency (dosage) may vary
sitive such as egg protein or antibiotics.
DISEASE IMMUNIZING AGENT AGE RANGE
ADMINISTRATION
(Intramuscular - IM)
PRIMARY
IMMUNIZATION
INTERVALS) BOOSTER DOSES COMMENTS
DIPHTHERIA,
TETANUS AND
PERTUSSIS
Toxoids of diphtheria and tetanus,
alum precipitated or adsorbed,
combined with pertussis antigen
(DTP)
For infants and children ages 6
weeks through 6 years.
4-8 weela At age 4-6 years,
6 -12 months preferably at
time of school
entrance. Dose:
0.5 ml, IM.
Do not use after 7th birthday.
TETANUS
DIPHTHERIA
(Por Adults)
Toxoids of tetanus and diphtheria,
alum precipitated or adsorbed,
combined. (Contains 1-2 Lf
units diphtheria toxoid.) (Td)
7 years through adult. Two doses: 0.5 ml ea. IM.
Third dose: 0.5 ml IM.
Every 10 years for
life.
For severe wounds, it is unnecessary
to use booster doses if the patieng
has completed a primary ly
and has had a booster dose with:
the preceding 5 years (within 10
years for clean minor wounds).
INFLUENZA Inactivated (killed) polyvalent, bi-
valent or monovalent influenza
virus vaccine. (Grown in chick
embryo tissue.)
All eges, from 6 months. Sea-
sonally for high risk groups
such as the elderly and those
with chronic illness.
May change from year to year.
See instructions on manufac-
turer's package insert.
Does not protect after exposure.
"Split", or "sub-unit" vaccine gen-
erally recommended for children.
POLIOMYELITIS Inactivated (killed) trivalent, poli-
ovirus vaccine (IPV) Types 1,2,3
combined.
All ages. Begin: 2 months. 4-8 weels
6-12 months
Booster dose every
S$ years through
age 17.
To be used in persons with altered
immune states and in their house-
holds.
Attenuated (live) trivalent oral po-
liovirus vaceine (TOPV). Types
1,2,3 combined.
Begin: 2 months.
Routine use in persons age 18
and over in the US. is not
needed.
Between Doses:
1 & 2: 6-8 weeks
2 & 3: 6-12 months
Preschool age (4-6
yrs.) and when
traveling to en-
demic areas. Re-
peated “booster”
doses are not
needed. Can be given to pregnant women in
outbreak situations. Avoid in
persons with altered immune
states.
MEASLES
(Rubeola) *
Attenuated (live) measles virus
vaccine
Age 15 months or older. 0.5 ml SC. One dose only. However, measles vaccine
should be given again if there is a history
of receiving a) killed measles vaccine
only, or live vaccine within 2 years of
receiving killed vaccine; b) vaccine before
the first birthday; ¢) live further atten-
uated vaccine with immune serum globulin
(ISG) or measles immune globulin (MIG).
Contraindications: Altered immune
states such as leukemias, lympi
oma, antimetabolite and radiaty
therapy, and generalized malig”
nancy. As with any live virus
vaccine, avoid during pregnancy.
Attenuated (live) mumps virus
vaccine
Age 12 mos. or older. * 0.5 ml SC. One dose only. As with any live virus vaccine, avoid
during pregnancy and in persons
with altered immune states.
RUBELLA * Attenuated (live) rubella virus
vaccine Susceptibles age 12 mos. or
older.® 0.5 ml SC. One dose only. MUST NOT BE GIVEN DURING
PREGNANCY. Women of chud
bearing age may be considered
for Immunization if advised of
necessity to avoid pregnancy for
three months following vaccine
administration. Avoid in persons
with altered immune states.
SMALLPOX: As of 1980 there is no medical indication for smallpox
attenuated vaccines are available for these viruses (Measles-Mumps-Rubella; Measles
*Combined '
older.
vaccination in any part of the world, except for persons handling variola/vaccinia-group vir ses in research laboratories.
~ hella; and Mumps-Rubella). If combined vaccine including measles vaccine is used, give “* age 15 months or
APPENDIX
31
APPENDIX A
REFERRAL OF CHILDREN TO CALIFORNIA CHILDREN SERVICES
California Children Services (CCS) is a program of physical
habilitation or rehabilitation for California children with specified
handicapping conditions. These children need specialist care, but
their families are unable, wholly or partially, to pay for these
services on a private basis. The program goal is to obtain for handi-
capped children the medical and allied services necessary to achieve
maximum physical and social function.
Federal regulation stipulates that anyone may refer a child
for diagnostic services. Timeliness is critical as it determines the
effective date of coverage. Referrals to CCS may be initiated by a
physician, hospital, the family or an agency.
If the physician has completed a diagnostic evaluation before
referral and is referring the child for treatment, a medical report should
be furnished to the CCS administrative agency so that an eligibility deter-
mination can be made. Emergency referrals may be handled by telephone.
The physician should instruct the family to contact the county
CCS agency immediately to complete the necessary application forms for
care under this program.
Hospitals participating in the CCS program agree to inform the
family about the availability of CCS services at the time of admission, if
the child is suspected of having a CCS eligible condition.
The CCS program will assume responsibility for costs of hospital-
ization only when prior written or verbal authorization has been given by
an official representative of the CCS authorizing agency, and the patient
meets CCS eligibility requirements. Physicians authorized for care of
patients are not empowered to authorize initial hospitalizatteoos or extensions
on behalf of the agency.
The family may choose any specialist participating on the CCS panel.
In most instances, a particular specialist is requested at the time of
referral by either the family or the referring physician. Specialists also
may refer and request assigmment of children to themselves, if appropriate.
When a physician has not been so designated, the agency assigns the child to
an appropriate panel specialist on a rotation basis. It is assumed that the
same physician=patient relationship will be established for the CCS child as
exists for other private patients under the physician's care.
Treatment is provided through CCS for most catastrophic or severely
handicapping conditions, such as severe orthopedic conditions, conditions
leading to the loss of vision or hearing, diseases of the blood or respiratory
systems, etc. Information on which conditions are CCS-eligible is available
from your county CCS program or Health Officer.
Source: California Children Services, California Department of Health Services
12/82
# a APPENDIX B
GUIDELINES FOR BODY WEIGHT
METRIC
Men Women
Weight (kg)! Weight (kg)!
Height! Acceptable Acceptable
{m) Average Weight Average Weight
1.45 46.0 42 53
1.48 46.5 42 54
1.50 47.0 43 55
1.52 48.5 44 57
1.54 49.5 44 58
1.56 50.4 45 58
1.58 55.8 51 64 51.3 46 59
1.60 57.6 52 65 52.6 48 61
1.62 58.6 53 66 54.0 49 62
1.64 59.6 54 67 554 50 64
1.66 60.6 55 69 56.8 51 65
1.68 81.7 56 yi 58.1 52 66
1.70 63.5 58 73 60.0 53 67
1.72 65.0 59 74 61.3 55 69
1.74 66.5 60 75 62.6 56 70
1.76 68.0 62 77 64.0 58 72
1.78 69.4 64 79 65.3 59 74
1.80 71.0 65 80
1.82 72.6 66 82
1.84 74.2 67 84
1.86 75.8 69 86
1.88 77.6 71 88
1.90 79.3 73 90
1.92 81.0 75 93
NONMETRIC
Men Women
Weight (1b.)! Weight (1b.)!
Height Acceptable Acceptable
{ft., in.) Average Weight Average Weight
4 10 102 92 119
4 11 104 94 122
5:0 107 96 125
B-1 110 99 128
B.2 123 112 141 113 102 131
5.3 127 J 115 144 116 105 134
5 4 130 118 148 120 108 138
5 5 133 121 152 123 111 142
5 6 136 124 156 128 114 146
5 7 140 128 161 132 118 150
5 8 145 132 166 136 122 154
5 9 149 136 170 140 126 158
510 153 140 174 144 130 163
511 158 144 179 148 134 168
6 0 162 148 184 152 138 173
6 1 166 152 189
6 2 171 156 194
6 3 176 160 199
6 4 181 164 204
1 Height without shoes, weight without clothes.
Source: Bray, G.A., (Ed.) Obesity in America, NIH Publication No. 80.359, U. S. Department HEW.
Adapted from the recommendations of the Fogarty Center conference on obesity, 1973.
12/82
33
APPENDIX C
SCOLIOSIS SCREENING AND REFERRAL CRITERIA
NORMAL PHYSICAL SIGNS OF CURVE
BACK
T0
SCREENER
FORWARD
BEND
AWAY FROM
SCREENER
SIDE
FACING
SCREENER
BEND WITH
SIDE
FACING
SCREENER
FORWARD
BEND
TOWARD
SCREENER
A Shoulders level.
(
;
Scopus ore level \
ond symmetricol. .
7 \ Body to orm distonce JA
| equol on both sides. ‘ \
7 THORACIC
: SCOLIOSIS
Slight Slight forword
bending will
demonsiraole 0
thoracic
prominence.
Mild thorocic posterior
) curve, neck erect, {)
head balanced.
( Lower bock slightly
hollow.
Snooth line
from pelvis
to heod.
% Normal rid
jj coger
symmetricol.
One shoulder morkedly
higher con indicate o
high thorocic curve.
THORACIC SCOLIOSIS
One scopule is elevoled.
Hip appears higher.
Body lo orm distonce is
unequal in lumbar scoliosis.
LUMBAR SCOLIOSIS
Further bending will
demonsirote ¢ lumbor
prominence.
THORACIC KYPHOSIS
Upper bock is morkedly
rounded posteriorly. Neck
8 chin forword moy be
gtsocicled with lumbor
lordosis.
LUMBAR LORDOSIS
Morked hotlow in lumber
area vsuolly ossocioted
with cbdominal protuberonce.
THORACIC KYPHOSIS
Exogqerated ongle in the
spine.
THORACIC SCOLIOSIS
Rib coge is prominent on
one side.
mmo tmant AF TAurariann
APPENDIX OD
CHILD ABUSE
MEDICAL AND NONMEDICAL PRACTITIONER'S RESPONSIBILITIES
WHAT IS CHILD ABUSE?
Child abuse is any act of omission or commission that endangers or impairs a child’s physical or
emotional health and development, including:
o Physical abuse and injurious corporal punishment—Intentional, deliberate assault, often the
result of overpunishment. This category includes physical injuries, such as: burns, head
injuries, shaken infant syndrome, bruises, abrasions, lacerations, scars and fractures, or other
injuries such as those caused by whipping or pummeling.
Physical neglect—The failure of a parent or caretaker to provide adequate food, shelter,
clothing, protection, supervision and medical and dental care, or otherwise endangering or
injuring the person or health of the child (environmental failure to thrive).
Sexual abuse—Incest, oral copuladon, sodomy, penetration of a genital or anal opening by a
foreign object and/or other forms of sexual molestation. Signs might include venereal disease
of the eyes, mouth, anus or genitals of the child.
Emotional abuse or mental suffering—Includes excessive verbal assaults, constant family dis-
cord and continual negative moods. Emotional abuse may be reported, but must be reported if
the abuse is willful and causes unjustifiable mental suffering.
WHO ARE THE ABUSERS?
Child abuse occurs in all cultural, ethnic, occupational and socio-economic groups. Frequently,
abusers had deficient childhoods or were abused themselves. They tend to be socially isolated and
they are often experiencing marital and/or emotional conflicts.
Child abuse usually is not a single act, but is typically a repeated pattern of behavior that increases
in frequency and severity. Abusers often take their child to a different doctor or hospital for treat-
ment of each new injury, making it difficult to detect a pattern of abuse. In order to identify
patterns of abuse, a statewide central index has been established. The reporting laws require that
child protective agencies (police and sheriff’s departments, county probation departments and
county welfare departments) send reports of all child abuse cases (except general neglect) which
they investigate to the Department of Justice Central Registry (Penal Code Section 11169). Early
reporting will provide early detection of patterns of abuse and, it is hoped, prevent permanent
damage or death to a child.
Source: Crime Prevention Center, California Department of Justice.
WHAT ARE INDICATORS OF ABUSE?
The following symptoms and/or conditions should be recognized by hospital, medical and non-
medical personnel as indications of possible child abuse:
Statements by the child that injury(ies) was caused by abuse.
A history of repeated injuries.
Delays in secking medical care.
Discrepancies in explanations of injuries, or inconsistencies between explanations, history and
the nature of injuries.
Injuries not reported by parents and found in physical examinations and/or X-rays.
Generally inadequate nutrition and poor health.
Extremely passive, compliant or fearful behavior demonstrated by the child.
Any evidence of sexual activity or abuse (discovered by 2 physical examination or the medical
history).
Injuries not explained by the medical history.
Any injury not consistent with the age or development of the child; e.g., bruises or broken
bones in an infant or toddler (particularly under three years of age) or bruises or broken bones
in atypical places.
X-rays showing chip or metaphyseal fractures (a result of jerking on a limb), posterior rib
fractures, spiral fractures (the result of a twisting injury).
Head injuries.
Abdominal and/or other internal injuries.
Inappropriate behavior of parents (overreact or underreact; cannot remember how injury
happened; insensitive to child’s pain or condition; refuse consent for further examination of
child; blame others; appear detached or apathetic).
Medical personnel should also be alert to ‘hospital shoppers.” These are people who, for no
apparent reason, have brought an injured child to a hospital outside of their community when their
own community has fully equipped facilites. Medical records sometimes reveal a history of hospital
or doctor “shopping.” Alone, this may not be indicative of abuse, but if found in conjunction with
other factors, the existence of abuse should be considered.
WHO MUST REPORT CHILD ABUSE?
Penal Code Section 11166(a) provides, in part:
. . any child care custodian, medical practitioner, nonmedical practitioner, or em-
ployee of a child protective agency who bas knowledge of or observes a child in his or
her professional capacity or within the scope of his or her employment whom he or she
knows or reasonably suspects has been the victim of child abuse shall report the known
or suspected instance of child abuse to a child protective agency immediately or as
soon as practically possible by telephone and shall prepare and send a written report
thereof within 36 hours of receiving the information concerning the incident. For the
purposes of this article, ‘reasonable suspicion,’ means that it is objectively reasonable
for a person to entertain such a suspicion, based upon facts that could cause a reason-
able person in a like position, drawing when appropriate on his or her training and
experience, to suspect child abuse.” (Emphasis added.)
3}:
“Medical practitioner” means a physician and surgeon, psychiatrist, psychologist, denust, resident,
intern, podiatrist, chiropractor, licensed nurse, dental hygienist, or any other person who is
currently licensed under Division 2 (commencing with Section 500) of the Business and Professions
Code. (Penal Code Secuon 11165(1).)
“Nonmedical practitioner’ means a state or county public health employee who treats a minor for
venereal disease or any other condition; a coroner; a paramedic; a marriage, family, or child coun-
selor; or a religious practitioner who diagnoses, examines, or treats children. (Penal Code Section
11165()).)
The duty to report child abuse is an individual duty and no supervisor or administrator may impede
or inhibit such reporting duties. No person making a report shall be subject to any sanction for
making the report. (Penal Code Section 11166(e).)
To assist in determining whether an incident is reportable, you can ask yourself the question, “Do
I suspect, based on my training and experience, that the injury was not accidental or not self-
inflicted?” If the answer is “yes,” the incident is reportable. Actually, if you must ask yourself
whether the incident is reportable, it probably is reportable. It is not the duty of the person who
reports to determine whether abuse actually has occurred. This responsibility belongs solely to a
child protective agency.
When two or more persons who are required to report are present and jointly bave knowledge of
a known or suspected instance of child abuse, and when there is agreement among them, the tele-
phone report may be made by any one of them selected by mutual agreement, and a single written
report may be made and signed by the person selected. However, if any person so agreeing knows
that the person designated to report failed to do so, that person then has a duty to make the report
himself/herself. (Penal Code Section 11166(d).)
A physican and surgeon or dentist, or his or her agent(s) at his or her direction, may take full
skeletal X-rays of a vicim of suspected child abuse without the consent of the parent(s) or
guardian(s) for the purpose of diagnosing the existence and extent of the abuse. (Penal Code
Secton 11171(a).)
The law specifies that the physician-patient and psychotherapist-patient privileges are not applicable
to information concerning known or suspected child abuse (Penal Code Section 11171(b)) and clan-
fies that the privileges do not excuse or bar reporting as required by law. Knowledge of child abuse
acquired through communication with a patient, whether the patient is the victim or the abuser,
must be reported. (Penal Code Section 11166(a).)
WHERE DO 1 REPORT CHILD ABUSE?
The reporting person must immediately telephone the report to a child protective agency of his or
her choice, and then send a written report within 36 clock hours to the agency selected (i.e., police
or sheriff’s department, a county probation department or a county welfare department). Reports
must be made on Department of Justice form SS8572 (Suspected Child Abuse). For medical
practitioners, Department of Justice form 900 (Medical Report—Suspected Child Abuse) must be
completed as well. If sexual assault is suspected, then Department of Justice form 923 (Medical
Report—Suspected Sexual Assault) should also be filled out. If these forms are needed for your
hospital or office, they can be obtained from a child protective agency.
12/82
WHAT IS THE LIABILITY OF PERSONS REQUIRED TO REPORT?
Penal Code Section 11172(b) states, in pertinent part:
“ Any [person required to report] who fails to report an instance of child abuse which
be or she knows to exist or reasonably should know to exist, . . . is guilty of a mis-
demeanor and is punishable by confinement in the county jai for a term not to exceed
six months or by a fine of not more than five bundred dollars ($500) or by both.”
(Emphasis added.)
Failure to report suspected child abuse may result in civil liability as well. A person required to
report suspected abuse who fails to do so may be held liable to civil damages for any subsequent
injury to the child. (Landeros v. Flood (1976) 17 Cal. 3d 399.)
The court may appoint a guardian ad litem for the victim under Welfare and Institutions Code
Section 318 to represent the victim in a Welfare and Institutions Code Section 300(d) dependency
action. The guardian ad litem must investigate for failure to report. He/she has access to certain
medical records, including those of hospitals and medical or nonmedical practitioners. (Welfare
and Institutions Code Section 318(e).) If a violaton has occurred, the guardian ad litem must
report to the court, and the court must then take appropriate action. (Welfare and Institudons
Code Section 318(d).) Appropriate action may include ensuring that civil proceedings against the
person failing to report are commenced (the consent of the victim is not needed).
WHAT PROTECTION DOES A REPORTING PERSON HAVE?
The identity of all persons reporting “suspected” child abuse must remain confidential and be
disclosed only between child protective agencies or when needed for specified court actions or by
court order. (Penal Code Section 11167(c).)
Those persons required to report, such as medical and nonmedical practitioners, are not lable for
either civil damages or criminal prosecution as a result of making a report as required by law. Otber
persons are not liable either civilly or ciminally for reporting, unless it can be proven that a false
report was made, and that the person knew that the report was false. (Penal Code Section
11172(a).)
Failure to report child abuse is heavily sanctioned, whereas compliance with the law ensures protec-
tion against civil and criminal liability.
37
WOMEN, INFANTS, AND CHILDREN (WIC) SUPPLEMENTAL FOOD PROGRAM
APPENDIX C
The California Women, Infants, and Children Supplemental Food Program (WIC)
improves program participant's nutritional status. The program integrates
health care with nutrition education and supplemental foods. The following
services are provided under the WIC program:
Health Care
* Physicians refer patients with health problems related to nutrition to WIC.
* WIC requires that all participants receive regular medical assessments.
* WIC encourages participants to obtain complete preventive care.
Nutrition Education
* WIC provides diet evaluations for all participants.
* Group and individual education sessions include discussions of topics such
as prenatal nutrition, infant feeding, anemia, and weight control.
* High-risk participants receive dietary counseling from Nutritionists/Regis-
tered Dietitions.
Supplemental Foods
* WIC provides participants with extra foods at no cost.
* Foods can be purchased at most community retail food stores with food vouchers.
WIC foods are specifically chosen to provide vitamins A, C, D, irom, protein,
and calcium.
Foods are meant to supplement an individual's diet, not provide total nutrient
needs.
The following are the eligibility criteria for the WIC program:
1. A woman must be pregnant, breast-feeding, or have recently delivered a baby.
2. A child must be under five years of age.
3. Participants must also:
(a) Receive regular medical assessments.
(b) Be determined at nutritional risk by a health professional.
(¢) Meet income guidelines.
(d) Reside in a local agency's service area.
Further information about the WIC program may be obtained by calling your local
health department or WIC agency.
Source: Women, Infants, and Children Supplemental Food Program, California
Department of Health Services
APPENDIX F
THE WORTH FOUR-DOT TEST
This device facilitates vision screening of young children mature enough to
count five objects and distinguish red, green and white. It can identify
suppression and diplopia.
Equipment needed is an eyeglass frame with a red lens for one eye and a green
lens for the other and a flashlight (or light-box) masked except for four
circular apertures arranged in the form of a cross with the upper filtered
diffused white, the lower red and the two lateral green (fig. 1). The trans-
mission curves of the glass or plastic filter material should be exclusive,
i.e., when the green light source is viewed through the red filter, no light
should be perceived.
— White
The Worth Four-Dot Test
Colors should be translucent and of approximately equal
brightness. |.e., when viewed through the red filter,
two equally bright spots should be seen.
Figure |
The test is conducted in a darkened room. With the red-green spectacles in
place and the target at least two meters from the subject, the light-box is
turned on and the child is asked, "How many spots do you see?'" A response
of "four" indicates normal binocularity and fusion as the two green targets
are seen by one eye only, the red target by the other eye only, and the white
target by both eyes. Valid responses are:
Response: Interpretation:
Fusion Binocularity
Four Normal Normal (no suppression)
Three green Not determined Suppression of red eye
Two red Not determined Suppression of green eye
Five: three green, two red Diplopia No suppression
Source: Vision Care Program, California Department of Health Services
10
It is recommended that a response of '"three green' or "two red" be verified
by having a second pair of red-green spectacles available with the colors
reversed, eye for eye, retesting the child after a few minutes without his
or her knowledge that the spectacles have been switched. If the response is
now ''three green' instead of "two red" (or "two red" instead of "three green'')
the presence of suppression is verified and referral is recommended. A find-
ing of diplopia should be verified by the monocular cover test prior to re=-
ferral; similarly, a finding of diplopia under cover should be verified by
the Worth four-dot or equivalent test.
A response of "five: three green, two red" should be confirmed by giving
the child a few seconds to fuse the white target and asking if he or she
still sees five spots. If so, it should be determined whether the top (white)
spot is seen as separated laterally or vertically, occasionally the subject
will report the singly perceived white target as two because it appears to be
alternating color from red to green.
A Worth four-dot test can be assembled from plastic filter material, one or
two frames, and a flashlight. Commercial sources of the Worth four-dot test
or equivalent test equipment include:
Bernell Corporation, 422 East Monroe Street, South Bend, Indiana 46601
Precision Professional Products, Inc., 2076 South Main St., Carson, CA
90745
Western Optical, Ophthalmic Instrument Division, 1200 Mercer St.,
Seattle, WA 98109
The three figure test, which utilizes red, green and white readily recognized
figures, such as animals, is an equivalent variation of the Worth four-dot test.
Reference: Duke-Elder, Sir Stewart and Wybar, Kenneth. (1973): System of
Ophthalmology, VI:408.
APPENDIN G
PURETONE AUDIOMETRIC SCREENING QUALIFICATIONS AND STANDARDS
Qualifications
The qualifications required to perform a puretone audiometric screening procedure utilized by the
Child Health and Disability Prevention Program are as follows.
(2) Completion of required training in audiometry from the State Department of Health Services or
through a program approved by the State Department of Health Services. Such training must
include a minimum of eight hours of academic preparation.
(b) Participation in a two-hour minimum screening practicum which includes observation and
record keeping.
(¢) Completion of the screening practicum (b) to update a screener if a screener has not adminis-
tered a hearing screen within the past year.
Testing Standards
(2) Puretone audiometers used for hearing screening tests shall be those manufactured to meet or
exceed specifications for wide range audiometers or Limited range audiometers as defined by the
Amencan National Standards Insurute (ANSI) S 3.6-1969.
(b) Electric-powered audiometers (as opposed to battery-powered) are recommended for their
accuracy and long life. Those currently utilizing a battery-powered audiometer must adhere to
all requirements 1n sections (c). (d), (e), and (f) below. Additionally. all batteries are to be
checked for proper voltage prior to performing screenings. When the battery-powered audi-
ometer no longer meets ANSI specifications, the replacement for it shall be an electric-powered
audiometer.
(¢) When testing by air conduction. both subject's ears shall be covered with an earphone and
cushion. (ANSI $3.6-1969. 3.2 and 3.3)
(d) The use of speech materials is not an accepted procedure because of the failure of these materials
in idenufving individuals with hearing impairment in the frequency range above 500 Hz.
(e) Each dav the audiometer is in use each earphone should be checked on a person with known
stable audiometric threshold that does not exceed 25 dB hearing level at any frequency tested
between 1,000 Hz and 4,000 Hz. Then the test results are compared with the subject's known
baseline audiogram.
(f) Checks to determine the environmental noise effects must be conducted on a “*normal hearing
person.” Thresholds on the audiometer may not exceed 15 dB at any given frequency.
(8) An electroacoustic calibration check of audiometers shall be made at least every 12 months or
more frequently if indicated. The following measurements shall be included:
(1) Puretone levels.
(2) Puretone frequencies.
(3) Rise/decay time for puretones.
(4) Harmonic distortion of puretones.
(5) Signal-to-noise ratio for all outputs.
(6) Attenuator linearity.
(7) Free of shock hazard.
If the audiometer fails to meet anv of the ANSI S 3.6—1969 specifications for the parameters
listed above, electroacoustic adjustments must be made and all standards met before the audi-
ometer may be used for testing.
A calibration chart showing proof of performance must be kept with the audiometer.
Com nan
4]
+
Sate of Can'orna—=eaith 470 Wa tare Agency
~2PENDIY =
eser mer Det Ser, cy
CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
CHOP SERVICE
emer ec. CT X=TTE—T ST 2
CHOP REFERRAL CRITERIA
HISTORY /PHYSICAL
EXAMINATION ' Revesit 8 1UIDECIE0 Medica Of OEVEICDMeENtsl Problem(s)
LENGTH/HEIGHT &
WEIGHT
Problem Infant /P repubectal Adolescens
Unoerwe ont Be ow 5th percentiie weight -for-neignt 10% below sversge valve we gri-tor-ne.gnt
Overweignt ADove 351M percentile weignt-for<naight 20% above average vaiue we gnt1-for-Negnt
Shor stature Beow 5th percontiie height forage
S.grificantiv changes percentile levels over ime which may indicate favre 10 thr.ve ODesIty, OF
other pathology
HEAD CIRCUMFERENCE Sgnificantly changed percentile ‘eves Over ime
BLOOD PRESSURE ; Age Courseling snd Surveillance Refer For Diagnosis and Trestment
{Unger 8 vesns : 11%/7% to 120/80 Over 120/80
i8 through 12 years 125/80 to 130/8% Over 130/85
{Over 12 yean 135/85 10 140/90 : Over 140/90
ARTERIAL PULSES {Femoral and brachial (Or racial) Duises absent 10 DEIDELION.
1
SPINE Evidence of deformity or sbnormairty by:
High shouloer Curved spine
Uneven hip of Unequa! am 10 body
west Creeses SOC ON HOTh nice
Uneven nippig line
Accentusted rou ~3 Deck
AcCContusted rwaybeck
DENTAL INSPECTION | Active infection Mslocciusion Cones
Pain intismmation of gums Missing resem
{Gross abnormalities Plaque deposi
NUTRITIONAL
ASS ESSMENT
{Delayed grown Ansmia (see hemogiobin/hematocnt:
{Uncerwe ight See above Insdequate/ inappropriate 100d intake Dy history
Overweight
DEVELOPMENTAL
ASSESSMENT
ISusoecten deve.comenta! geisy
VISION SCREENING
Clinical Assesment
Perurtent symptoms by hestory Problems cheerved on phywca! saamingbon
Double vision Redness Lice Abssnt/edn orma!
Visua! cucomfion Swelling Conjuncuving reg reflexes
Fatgue ss0ciated Bleecing Unequai pupits Strabismus
with use of eyes Pus Cloudy media Suppression
Fundus sDNOr™Mai ties
Veus! Acuity [Under 6 years of age § vears of age and over A g.fference of two ines 0°
120/50 or wore. either eve 20/40 or worse, either eye more on the Sneier chp~
HEARING SCREENING
Nomsudiomet
Auchomeme
Hwtory Problems observed on physical examination
{Possible hearing imps rment infant's response 10 sound Pathology i dlls 0
Abtant biinking refiex Otius med.s
: : Absent startle reflex {acute or chron)
! ; Absent arousal response Externs outs
; Failure 10 respona te screening level of 25 ¢B #1 1.000. 2,000. anc 4 000 Hz. in either esr (3.00C 2 optional)
TUBERCULIN TEST
Mantoux Test
Multiple Puncture
{Read at 48-72 hours after administration
10 mm or iarger refer for duagnonis/trestment
[High-risk inOnviOus: — 5—9 mm refer for disgnosis/trestment
!No known contact — 5-9 mm, repeat
[ Vesicuiar reaction, refer for diagnosis. tregtment
| Any other action, retest with Mantoux
Call the ioca/ heelth department f there are any Questions regarding interpretation of either test, kagnos:s, or treatment
HEMOGLOBIN/
HEMATOCRIT Evalustion end Disgnosis,
i Education if Trestment
i Sex Below it Below
| Both 110m 10.0 gm
: Both 12.0 gm 110m
| Mare 13.0 pm 120m
| Female 120 gm 110m
i
i
1
i
i
Hematocrit® Both MO0% 00%
Both 370% 330%
Male 410% 370%
|
|
Female 30% | 30% |
Adjust the Remogiodin 3nC NEMITOCTIt values 8t high altitudes as follows:
* Less than BOO meters (2,624 feet) sbove soa lovei—no adjustment.
eo BOO-1.300 meters (2 6244 265 feet) above 18s love! —acc 0.5 gm hemoglobin and 2 hematocrit points.
° Over 1.300 meters (4,265 feet) above ses level—sdd 1.0 gm hemoglobin and 3 hematocrit points
URINE
(DIPSTICK/URINALYSIS)
1Sugar- 1+ and/or Protein: 2+ and/or Blood: unexplained presence
PHENYLKETONURIA (PKU) Presumptive positive
{One repest test uncer age 1 mo. [or at first weii-baby check-up] permitted Hf initital test done at iess thar 24 mrs of age)
SICKLE CELL
ELECTROPHORESIS
| {To be performed if nemogiobin K 11 gm or hematocrit € 34% in Black person of persons whose ancestors came from
areas near Mediterranean Ses or Indian Ocear..i When positive for disesse, refer for diagnosis, treatment, and counseling.
. When positive for trait, refer 10 8 qualified counseior. (Also refer for other hemoglobinopathies getecreo.)
GONORRHEA CULTURES) Positive from any site. (To be gone when ing.cated by history, sexua! activity.)
PAPANICOLAOU SMEAR : Crass |i or spove (Pe-formed at age 17-20 years. or younger if sexus!ty active.)
‘LEAD POISONING
Fros Erythrocyte
Br ea es AE DY
iT2 pe per‘ormec wher his107v "eves:s DIC3 behavior, ¢ g., 1ngesuon of paint chips. colorec magazine pages, and sO eC,
RE Fe CL CR Le Nr Semi we ag? Fo tt rae . ri VOW re AE imme cepts
APPENDIX 1
NEWBORN SCREENING PANEL REQUIRED
A11 newhorns must be screened for preventable forms of mental retardation under new
regulations issucd by the Department of llecalth Services (17CAC6500). The Genetic
Niscausc Scction, Department of Health Services, has contracted with six clinical
laboratories to perform required tests upon Medi-Cal beneficiaries. The designated
scrcening panel consists of the following laboratory tests:
Radioimmune assay for T4
Radioimmune assay for TSH
Qualitative fluorometric blood phenylalanine
Galactose - 1 - uridyltransferase
Microbial inhibition assay for blood galactose
The laboratories listed below will perform these tests and be reimbursed under con-
tract by the Genetic Discase Section. The Genetic Disease Section then will bill
the provider who collects the blood specimen from the infant. The provider then
will bill the Medi-Cal program for reimbursement.*
Billing Instructions
Ordinarily, the specimen will be drawn by a hospital while the patient is an in-
patient and the hospital will bill the Medi-Cal program utilizing the laboratory
ancillary code, 4060.
When the service is provided on an outpatient basis by the hospital, clinic or physi-
cian, the service is to be billed utilizing a unique billing code, 89010 with modi -
fier -90. Newborn screening under code 89010/90 will be reimbursed only once per
infant and only for infants under one year of age. In addition, to be reimbursed
under this code, the panel test must be performed by one of the designated contract
laboratories and the specimen, when submitted to the laboratory, must be collected
and submitted on a Genetic Disease Section Specimen Collection Form (PM 165-1).
When the panel test is performed independent of the newborn screening program, it
must be billed utilizing 1974 RVS/CSN codes 80120, 83537, 84443, 84031, 82776, or
82760. If billed with CSN code 89010, the service must be a part of the screening
program sponsored by the Genetic Disease Section.
The designated laboratories are:
WESTERN CLINICAL LABORATORY AMERICAN CLINICAL LABORATORY
408 SUNRISE AVENUE 10477 - C ROSELLE STREET
ROSEVILLE, CA 95678 SAN DIEGO, CA 92121
ALLIED MEDICAL LABORATORY REFERENCE LABORATORY
20392 TOWN CENTER LANE 1011 RANCHO CONEJO BLVD.
CUPERTINO, CA 95014 NEWBURY PARK, CA 91320
FRESNO COMMUNITY HOSPITAL MEMORIAL HOSPITAL OF LONG BEACH
AND MEDICAL CENTER 2801 ATLANTIC AVENUE
FRESNO AND "R' STREETS LONG BEACH, CA 90806
FRESNO, CA 93715
Source: Medi-Cal Provider Manual for Medical Services, Program Policy Statements,
pp. 3-66 and 3-77, April 1983. 4 hu Medi-Cal. the provider, i.e., hospital,
. V
ilt . APPENDIX J
MENDED OTP/OPY IMMUNIZATION SCHEDULES AND STALE REQUIRDENT
FOR CHILD CARE CENTER AND SCHOOL ENTRY é
legal school and child care center entry requirements for diph-
anus/pertussis (DTP) and oral polio (OPV) vaccines (Health and
;2 Jection 3221; and California Administrative Code, Title 17, Sec-
Child care center Kindergarten/first
entrants over ace 18 mo. grade entrants
“e'Y
i/o ¥ ww
) doses At least 3 doses. If the
third or last dose was given
before the second birthday,
one more dose is required.
gh L doses At least L doses. If the
fourth dose was given before
the second birthday, one more
dose is required.
A physician may give a child a written medical exemption to any immunization
requirement if s/he feels it is medically contraindicated for that child
{teelth and Safety Code, Section 3386).
Talifornia's legal requirements were devised after consultation with several
rediatricians, and are an attempt to approximate a minimum standard for full
immunization in accordance with the schedule recommended in the Report of
the Tormittee on Infectious Disease; American Academy of Pediatrics, 1982
[i.e., the 1982 "Red Book"). For children who complete their primary series
© T° and OPV on time (i.e., who have received their 4th DTP dose and 3rd
CPV Zose at age 18 months), a booster dose of each vaccine is recommended
at age 4-6 years, when the child enters school (kindergarten).
rom the "Ped Book" the Academy's language on this point:
I excerpt
2PV (p. 208) - "For children who complete the primary series of
3 or nore doses at about age 18 months. . .a supplementary dose
should be given prior to entry into school (4 to 6 years old)."
(Underscoring added.)
DTP (p. 200) - "Routine follow-up injection of DTP. . .should be
riven about 1 year after completion of the primary series, and
2zain before school entry." (Underscoring added.)
ae believe that giving these booster doses before kindergarten entry is
reasonable since a) school entry usually means onset of exposure to many
more children, bY) the protective effect of pertussis vaccine may wane
within a few years (Aftandians RV: Amer J. Epidem 99:343, 1974; Lambert
HJ: Public Health Rep 80:265, 1965), and ¢) young children receiving a
8/83
45
primary series of Just three OPV doses do not uniformly <evelop seroloric
evidence of immunity to all three poliovirus types (Lany ME: Dev Eicl Stand
L3:207, 1979; Kaplan AS: Zh Mikrobiol Epidem Immunobiol 1:115, 197%).
OF course, these kindergarten entry booster doses are not as necessary in
children who begin and complete their primary DTP and OPV doses later in
life. In an effort to approximate a minimum acceptable standard, wnich is
more lenient than the American Academy of Pediatrics' recommendation on this
point, our law drops the kindergarten entry dose requirement for children
who complete their DTP and OPV primary series after the second birthday.
If you have questions or comments please feel free to contact me.
Source: June 15, 1983 memo to interested physicians from Loring Dales, ¥.D.,
Immunization Unit, California Department of Health Services, phone
(415) 540-2065.
16
APPENDIX K
IMMUNIZATION RECOMMENDATIONS FOR CHILDREN WITHOUT IMMUNIZATION RECORDS
wet infrequently, children placed in foster homes, children from foreign
countries, or simply pupils entering schools are found to lack immuniza-
tion records, yet the suspicion exists that they have indeed received at
least some immunizations in the past. How should these children be handled
with regard to routine immunizations? The Infectious Disease Section rec-
ommends that these children be fully immunized appropriately for their ages
under the assumption that they have received no prior immunizations.
Peirmunization with the commonly used live virus vaccines--measles, rubella,
mumps, and oral polio vaccines--poses negligible risk. In immune persons,
these vaccines simply fail to "take" (i.e., to set up an immunizing infec-
tion) and cause no reaction. Evidence of the harmlessness of repeated doses
of certain live vaccines are recommendations made in some quarters for a
routine two-dose measles and rubella immunization series (Krugman S: Pedi-
atrics 65: 1174, 1980; Balfour HH, Jr: Amer J Dis Child. 123:1231, 1979)
and the recommendation for a supplementary dose of oral polio vaccine for
persons who have been fully immunized several years previously but face in-
creased risk otf disease exposure (USPHS Advisory Committee on Immunization
Practices: MMWR 28:518, 11/2/79; Centers for Disease Control: Health In-
formation for International Travel 1980, HHS Publication No. [CDC] 80-8280,
p. 29).
With the killed vaccines diphtheria-tetanus-pertussis (DTP) and tetanus-
diphtheria (Td or DT), administration to an already immune person may occa-
sionally result in an exaggerated local (Arthus) reaction. If this occurs,
the patient should be managed like any other DTP/Td vaccinee with a severe
local reaction, such as with termination of the primary series at that time
or change to another preparation (e.g., from DTP to Td or DT), depending on
clinical judgement as to what the specific circumstances indicate. The im~
portant point, however, is that an exaggerated local reaction is not a life-
threatening event or one which leaves permanent sequelae. Therefore, the
possibility of such a reaction should not be a deterrent to starting a pri-
mary DTP or Td series in a child with an unknown prior immunization history.
August 1981
Source: Immunization Unit, California Department of Health Services, phone
(415) SL0-2065.
INDEX
Blood lead level, 26
Blood pressure, 3
Body weight, guidelines for men and women, 32
Breast sclf<xaminauon, 6
California Children Services (CCS), 1, 31
Child abuse, 7
Mcdical and nonmedical practitioner's responsibilities, 34
Child Health and Disability Prevention (CIDP) Program referral criteria table, 42
Child Hcalth and Disability Prevention (CHDP) Program services, 1
Dental assessment, 6
Developmental history and assessment, 9, 14
Stages of age-related development, 10-13
Free erythrocyte protoporphyrin (FEP), 26
Gonorrhea culture, 26
Itead circumference, 4
lealth assessment procedures by age group, 2
tHicalth education
Definition, proccess, resources, 14
Suggested health education topics by age, 15-19
learning screening, 21
Auditory milestones, infant's first 24 months, 21
Puretone audiometric screening qualifications and standards, 41
Height, 3
Hematocnt, 23
Hemoglobin, 23
\ History, health, 3
Immunizations, 27
Recommended immunization schedule, 28
Immunization recommendations for children without immunizauon records, 46
Recommended DTP/OPV immunization schedules and state requirements for child care center and school entry, +4
Mantoux test, 23
Multiple puncture tuberculin test, 23
Ncwborn screening panel required, 43
Nutritional assessment, 7
Criteria for identifying nutritional problems, 8
Papanicolau (Pap) smear, 25
Physical examination, 3
Prior approval, procedures requiring, 27
Pulses, arterial, §
Rechecks, laboratory tests and procedures, 27
Sickle cell determination, 25
Spine, cxamination of, 6
Scoliosis screening and referral criteria, 33
Tubcerculin tests, 23
Urinalysis, 24
Urinc dipstick, 24
Vision screening, 20
PM 160 INSTRUCTIONS
COMPLETING THE SCREENING /BILLING REPORT
TABLE OF CONTENTS
Page
COMPLETED PM TOO==ROMTINE ............ovvcrcnnietssissessssssessivessesossrssrssroginensn domi, 5 ou 20 1
GENERAL INSTRUCTIONS FOR COMPLETING THE PM 160 .....coooiiieereeeeeeeeeeeseeenreeeeeeesssnns 2
PATIENT INFORMATION cc citei es sr rosrenrrrsssssssstasssthuses iiitsnsesnsssssmmmnss iv sh satis met esa oo 4
POISN INCITIB ats eadeaconerrisinrmensivessonsamasrsisissinss ssssssstssnresnsssns snnssosssirnnsrsins sirens do 4
BINGE ci senencsssrrdiuencssssonreraasntaifonsnsnsnrevnersniinriinnsinssvresssmsinmsessetsn vustinsin emai 4
IACI 1 sitesersrrusaivenursrniagnssssnsensssmmaseisrssssnssrrobumasmnssssavannsusnunnsinrsssssstrnnrrrsontansesnsrnits shines 4
SB Kor ivarisrsssssentesnsrossannerisnsesnissiassontusvhmmmuenrnsasiinsus iss srirsrrsssernassossorrDenvaivaitiooits oS 4
POE'S COUMY OF ROSICOIICO......cccmvriivinrissivrisiisrasrissnssssrmstoossssesstoerecotsirmniiie. 4
TOI CPIONE INUIIDIBE ..vrsss17031030ss00strssssrssessssssssestas seats strssnsrissounsssassresasetiase sans tinmmtrinne 4
ING XE VESIE yc resranasersarevionsersssssvessosverssnstsrssnsnatussriherisnsansessrennnsuvesssson som iinssinnintrrmribtscss 4
ROSPONSIIIG POISON cc ceucerrersrrninisstontorsermrmmsrsnsrrrvnrmnsrssrsnassessosstrsrnssverissssorsos sitasanei dition 4
BHI CC OCB... cesretasaieratasnsissseasionmmnronsnssssnubhtntesssraserssomsronstosssmmmenniiss ons vr en tensecasins 4
MEAICC ROCOIINUITIIOE .....covrsestocetorerrrninsssrmrerrssssnsmmsrrossioronsnsssivrmnses rasan 4
DATE OF SERVICE... ov vetisrensianyse suaivernnsssnanssdossissteriossinsnnsssanbennssnsssissusessrmiaasistnnsiastons iia | 6
COMPLETE HEALTH ASSESSMENT ......c.ovnncnerritiunssivsssstirrsasredessissnssssssorintduss main ih esasannnss 8
SCIBENINGD PrOCEOUIBS/C OBS ...crivsisccrirrnsimrisesientvinenicnsiismrrrssstsssstssssssnsiorns sreres sarin, 8
Assessment Procedures OUICOME CoOlUMINS..........ciiieiiieeeii eerie ersnnessreessseseesennnns 9
FOHOW ID CC OOIBE . .rueriverrinirismannsrersmsaidrmmrerssernervinsssssins sesso srnvisssssstnssshossiss sions 11
OTHER TESTS oooeeresssrnirnstecsesnnsrsesssaissnssiiorsnne seisusnsrsssressarsssonrrssonsssstododoture sss siioorsstrrssssnsnna, 12
HEIGHT, WEIGHT, BLOOD PRESSURE, HEMOGLOBIN/HEMATOCRIT ...coovviieiieeeeeeeeenn 13
REFERRED YC 1s0oanssrssntorasanssnrreerescsssarsssronivreneessuussiones cinsssmmsrrosssansssassiessrrsnnevibbnssiunsesnsisitim 16
IIA INTL AT COIINS eter sienmmse cs vanncusmntntss synttnsussns vanessa insormnssitonsensiedinivionm iia bo 720 17
PATIENT VISIT roa ic0nrerecossunesnsressonsesesnsatesseransmrnassssssnensnssstonsansvasson tot ines soma omin S SLE 21
New PAHEN OF EXISNUIGC VISH.....ccciteirrirrisrirsinmrersrsssisvereessssreiveris ining 21
ROUINE WISH. ccvrerrenivoesissrrsssesseinssssstossrersansnssssmtniesasnss vob rrsessonainnssossmmmssscessaraiiotss sods a 2 21
TY PE OE SC RE EIN J. it isstverseerseesrrereninsmrreenernrosriions sisininassrssornrsssrsnssstiiinimandinr Ln LTE 21
JIN ensivrnsissersnmassnstorseqsasnnessuinesssnatBeiorrintentensasronsnossssnnnbrborssibnsdosisniinsnmiabismomin no. 21
POIIOICHC . , re2020ndnsrsins sneressornnssssssnanaursiine cies iidirstssaenssssttons a votroniosss ernie 21
BR ES Lo. reese rare tinanasonssrunsonasevsvsunnevedsss on stenshonriniinas tars serssraatinsnnictoms isto ra T 22
MECC QO IIH OF COBY. oc cveeereerssetacntcrersies ssn rnrersennssrssishamns sssinvonssnssssrsirit i tris erssaass 23
PROVIDER OF SERVICE... veesscrssrresetunnvantucseussarssmarssstfrassenssssbonsinssrisaniioishoodiai 0 24
POV CIEE INUITYIEIBY ccterssasasersssoresasssssassasisnnnnasisivrrtrrrnnennnessstmmmmessssmnnsssssnsyesnciimsmisiniminins 24
Site Of SEIVICE Hf ONOT TROY ADOVE ...cvvvriccisiinssssssssssssinisssssssssserinsvsrssioveirssessotosees 24
SIGIYARITG OF PIOVIGIBE ..ccoririssistinrssorsssmmssrsssserrsssessssarrsnnnteminesusirnssnrrsstssssomssrsssboorns sis 24
COMMENTSIPROBLEIMES ...ooiveeecirecssarersnsosessesisesisnsassnissssessars ss insssroes sssesbonnonssiointbisisiommiiseg 25
TOBACCO USE QUESTIONS ov. civ erarsrerniurrnreirensisssnssessssesssrsrsssnsssosisnssbritrmorreresanin 27
ENROLLED IN WIC/REFERRED TO WHC o.oo coer irrrrrarrsavssssnssasssrsrairmmomssrsrvesssst sat ttss mss ase 28
PATIENT ELIGIBILITY 11000000es00eeseresens cusrrssesnrssessinernrrersrrrsnnrermmsessvrrarbossrrssiraeris mises st snes inant 30
MEO-C Ol PCHBIN. . esrrerrsrrcoressessesversreteessininirsns sn ssssssrenssssasnsissmninvsisnsisbos boot rnrrmssomoanics 30
Non-Medi-Cal State ReIMbBbUISEd PAHENTS .....cccuuuuieiiieiiiieeeeeieiesisessesessesees essen 32
HEAD START AND STATE PRESCHOOL CHILDREN .....ccoooviiiiiiiiieiiiiiiiieeeieeiseesssssnnsssessessssns 34
CLAIMING FOR OTHER THAN A COMPLETE HEALTH ASSESSMENT ..coooviiiieiieeeeeeeeeeeeoens 35
POMC SCIOOII=lNISITUCHOMNS crvccisrerrssivesivastiostsnnsssessvorebonssssnsinkunsusesintsrmmmmsianin © 35
Screening Procedure RECheCK—INSITUCTIONS ........coeeeeueeeeeeieeeeeieeeereeesee ee eseseesessas 36
Screening Procedure Recheck—Example—First PM 160 .......cooeeeeeeeeeeeeeeeeeesesenns 37
Screening Procedure Recheck—Example—Second PM 160 ..........ooovveveevvennn. 38
Claiming 101 O POMC SCIEBN—EXAMIPIG ... oc... cc cccirrrerreiansisrsississnssnsssssssareerrssnennns 39
4 Effective April 1990
PM 160 INSTRUCTIONS
COMPLETING THE SCREENING/BILLING REPORT
ATTACHMENTS
Page
COPY OF MEDI-CAL CARD ISSUED BY STATE.............ccccceinniiiirinnnnnmnnnnnnnnnnnnm 42
COPY OF MEDI-CAL CARD ISSUED BY COUNTY ........cccevrrieimmmminnminnnininnnn i. 43
RESIDENCE CODE LIST .ccceiiotiirtsisssmiemmrnrinricsincsssnuissicisnmuntpussionsmmnnsbtss asst 43005 rosa ga stats sssassanes 44
RECOMMENDED IMMUNIZATION SCHEDULE ........cciimimiiiiiinnni, 46
CHDP ELIGIBILITY INFORMATION — ENGLISH (DHS 4073 Bilingual) ........ccoouviiniiiiiniinnnn 48
CHDP ELIGIBILITY INFORMATION — SPANISH (DHS 4073 Bilingual) .........ouvvnniiniiinnnnn 49
HEALTH ASSESSMENT PROCEDURES REQUIRED FOR VARIOUS AGE GROUPS................ 50
SCHEDULE OF MAXIMUM ALLOWANGCES—FEES .........ccvviiiiniiiiiiniiniccnniinn, 52
ASIAN AND PACIFIC ISLANDER GROUPS ...........cccvinninnin nnn essen 54
PROTOCOL FOR ANTI-TOBACCO HEALTH EDUCATION ........cooiiiiiiiiniinincncnee 56
JCD -@ CODE LISTING ...cocereessrsssssrsnsrrrrirnnrsnsinissminsansesnniunsnssusenssrormsnnsenstssssisssassasstasssisrsvsons 58
EXAMPLE 1
CLAIM CONTROL NUMBER FOR STATE USE ONLY |
| STAPLE
20 NOF STAPL | HERE
[NAR AREA { |
TT |
3 Dot NT NAME Jane (FIRST (INITIAL) | MEDICAL RECORD NO LA Code |
f)
Aj
8 E OAT | AGE ccm) PATIENT'S COUNTY OF RESIDENCE COOE TELEPHONE NUMBER NEXT VISIT L Amencan inaun
el a
Dav 2 Avian
4) 5 251 g7| 3 i Spexpments 13415551272 63 91]: IE
. aL PER (NAME) on |B hihi reson
i oR Cod Fim Steel ~Sarsmento 938/14 Toi
| QEFUSED PEA OF 5 FOLLOW UP CODES
oy hE i an. ’ sw Is] UBL LN SURLMIEAIS 2 RoW 4. i JeuRinc/eeryry visit
Indicate outcome for each swseected | oO | NEW | KNOWN | 1 QUESTIONABLE RESULT, RECHECK REFERRED TO ANOTHER EXAMINER
screening procedure SCHEDULED
vA «8 c 0 | 1 DX MADE AND RX STARTED 5. REFERRAL REFUSED
i ERRED TO. TELEPHONE NUMBE=
01 HISTORY and PHYSICAL EXAM | 3] | / | a 30, 94 iin RoOLD Pow iss Off 510 12.34
02 DENTAL ASSESSMENT/REFERRAL | ho REFERED 10 | TELAT NuMge?
03 NUTRITIONAL ASSESSMENT | {<0
ga “ATIIATONY GLIANCE TV I | COMMENTS/P a
05 DEVELOPMENTAL ASSESSMENT! Vv | | | | If A PROBLEM IS DIAGNOSED THIS VISIT PLEASE ENTER
06 SNELLEN OR EQUIVALENT av | | 1 ls 4.00 | YOUR DIAGROSIS IN THIS AREA
07 AUDIOMETRIC FV jv 9. af |
08 HEMOGLOBIN OR HEMATOCRIT | Tog. 1% 2.0] | 101 Orr1rs /eorA - (3)
09 URINE DIPSTICK | id | | 09 wEMuULl 1)
10 COMPLETE URINALYSIS FV | | 0 of 57 He ART mM (
11 TB MULTIPUNCTURE | Ear A” | | J 11 |
12 TB MANTOUX } Vv | le 7.95 03 O1eTRY Couns LING
of |_ODEATSTS | SEE CODES ON REVERSE SIDE OF LAST PAGE __|CO0E| OMER TESTS 2 : 3 )
Ih Bigod LéAo oi | | 3122. % IviEN (
| |
I fromm} 02 Qentar Carzés (5)
2 1836210290370
® 0 D 7 x PE BIRTH WEIGHT OF HVEMIR (3)
| GIVEN TODAY | NOT GIVEN TODAY
IMMUNIZATIONS EE | Sn | Are | Ee : oy soen
| Sir : OKIE FOR | OATE FOR CNR. n 3 : | 3
| ¥ |u| 2 3F200117¢520 52/00
31 POLIO - ORAL | i. yf a | THE QUESTIONS BELOW
32 OPT Dt/Td | | [ ¥ In + MUST BE ANSWERED
IMMA MuR(C? MRC | |W, |= _. Ll. Patent 1s Exposed to Passive (Second Yesi No x
38 Hib CV | lv. In Hand) Tobacco Smoke. ne
| | — 2. Tobacco Used by Patient Yes No
|
| | | n 3. Counseied About/Referred For Yes NoWZ
PATIENT VISIT (y) TYPE OF SCREEN TOTAL FEES Tobacco Use Prevention/ = X
: iba grid | Acune Yar | = ee | Cessation.
PROVIDER OF SERVICE: Name. Address
[esepnone Number (Please Incrude Ares Coded
(1] Enrolled in WIC Referred to WIC
NOTE: WIC requires Ht.. Wt. and HG8/HCT
AIN
os a 95%1¢
SITE OF SERVICE IF OTHER THAN ABOVE:
[} PARTIAL SCREEN 'y a PROCEDURE RECHECK
This 1s to certify thot the screening information if true and compiete. and the resuits exploined to
the child or his parent or guardian. | understand that payment and satisfaction of this claim moy
be from Federal or State unos. ond that ony foise clowns, statements or documents of conceal-
ment of @ material fact. moy be prosecuted under oppicoble Federal or Store law. | olso certify)
thot e of the services billed on this torm hove been or will be biiled to Meai-Col, the
“Co Dd SH agusett ng 3/ / 90
SICH
|
ACCOMPANIES PRIOR PM 160 DATED !
PATIENT 13: 3 He NUMBER
ELIGIBILITY 15415% |G b n / Sb |
v It covered by Medi-Cal. enter Medi-Cal 1.0. sember above AND attach P 0 €. ladei
shaded ares below.
AJ Priest not oa MedeCal Porect or guardisa Mas fasd ang 310d thigidility Statement
RE OF PROVIDER DATE
CONFIDENTIAL SCREENING/BILLING REPORT
STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
COPY 1 - MAIL TO MEDI-CAL CHOP 4
Medi-Cal/CHOP
P.O. Box 15300
Sacramento. CA 958511200
GENERAL INSTRUCTIONS FOR COMPLETING THE PM 160
The Child Health and Disability Prevention (CHDP) Program's Confidential Screening/Billing
Report (PM 160) form is to be used by providers to request payment for health assessment
services given to CHDP eligible persons. (See Example 1 on previous page.)
This form documents the results of the health assessment and is shared with the parent/guardian
or patient and the local CHDP program. The PM 160 is used when claiming for a COMPLETE
HEALTH ASSESSMENT, a PARTIAL SCREEN, or a SCREENING PROCEDURE RECHECK.
A Complete Health Assessment must be done according to the "Health Assessment
Procedures Required for Various Age Groups," (see Page 50). Persons who have not
received all the recommended procedures for an earlier age should be brought up to
date, as appropriate. See "Billing Restrictions" of Provider Manual for additional information.
A Partial Screen is done to complete any assessment procedures that could not be
provided during the Complete Health Assessment or when immunizations only are given to
children not yet due for another Complete Health Assessment. In all instances, claims for
Partial Screens are only to be submitted on children who have had a CHDP assessment
and a prior PM 160 was submitted (see page 395).
A Screening Procedure Recheck is done when, during a prior CHDP health assessment, the
accuracy of the result of that procedure was questionable (see page 36).
The PM 160 form has four (4) copies:
Copy 1 (white) is to be sent in for claims payment to:
Medi-Cal/CHDP
P.O. Box 15300
Sacramento, CA 95851-1300
Copy 2 (yellow) is to be sent to the local CHDP Program to:
This is necessary so that the local program can meet its requirements which include
assisting children to obtain diagnosis and treatment services, if indicated, and periodic
notification of the next health assessment due.
Copy 3 (white) is to be kept in the provider's files.
Copy 4 (pink) is to be given to the parent/guardian or patient at the time of the
examination with a complete explanation of the results of the assessment.
A section to enter ICD 9 codes for diagnoses made is found in the "Comments/Problems" area.
Please see page 58 for the list compiled by the Academy of Pediatrics of the most commonly
used codes for children.
Prompt payment of claims is dependent on how accurately the PM 160 is filed out. Make sure
that:
| §
10.
11.
The PM 160 is filled out in black ink or typed. DO NOT use pencil or red ink. Press hard
so all four copies are legible. DO NOT USE "WHITE OUT."
The PM 160 is signed by the provider or designated representative. DO NOT use a
signature stamp.
The PM 160 is completely filed out for the type of assessment provided (Complete,
Partial, or Recheck).
All the required check marks (V), code numbers, and fees are entered.
The Provider Number is accurate. (Claims are automatically paid to the Provider
Number entered on the PM 160.)
The County Identification or the Social Security Number entered on the PM 160
belongs to that individual, and also make sure that (s)he was eligible for Medi-Cal in
the month services were provided. Attaching a Proof of Eligibility (POE) label to the
PM 160 is not required, but is recommended.
BOTH the county name and its code number for the patient's residence are entered.
All comments, concerns, or problems are entered in COMMENTS/PROBLEMS area.
The provider's name and return address are on the outside of the envelope and
legible.
Answers to Tobacco Use Questions are documented.
No staples are placed through the bar patch on the claims form.
Services provided to any persons enrolled in a prepaid health plan where preventive health
services are a covered benefit MUST NOT BE BILLED TO CHDP
Notify the local CHDP program immediately if there are any changes in provider information so
that the state CHDP Provider File can be updated. All provider information changes must also
be reported to Medi-Cal Provider Services.
PM 160 INSTRUCTIONS
COMPLETING THE SCREENING/BILLING REPORT
PATIENT INFORMATION (See Example 2 below)
TP 1 PATIENT N S FIRST) Ee i
f 0 al E GAT) tH (INITIAL) MEDICAL RECORD NO. CA Coe
0 ANE A [7723936 759)
} i Bo: AGE SEX ree: PATIENT'S COUNTY OF RESIDENCE CODE TELEPHONE NUMBER nexy VISIT
| Jy ay ar
10 Tr 3 Ew SneeBmento 134555 j212 03 97 |
|
' 0 dA PERSON (NAME) (STREET) (CITY) (ZIP)
3] bi 1184 Elm TIREET SheeAminid 45 81%
PATIENT NAME: Enter last name, first name and middle initial. If Medi-Cal Eligible, enter name
exactly as it appears on Medi-Cal card or POE label. If patient name differs in any way from the
name on the Medi-Cal label, enter the name the patient is also known as (AKA) within the
name block.
BIRTHDATE: Enter month, day, and year of patient's birth. Use 0's when entering dates of only
one digit; e.g., January 22, 1981 = 01/22/81.
AGE: Enter the patient's age.
SEX: Circle F if the patient is female; circle M is the patient is male. (If sex stated on POE label is
incorrect, note in "Comments/Problems" area.)
PATIENT'S COUNTY OF RESIDENCE AND CODE: Enter both the name and appropriate code of the
county where patient lives (not county where assessment is done). See page 44 for county
code numbers list.
TELEPHONE NUMBER: Enter residence, business or message phone number where responsible
person can be reached during the day. If county includes more than one area code, enter
appropriate area code.
NEXT VISIT: Enter month, day, and year of the next Complete Health Assessment. See Periodic
Appointment Schedule, (page 50.) Use O's when entering dates of only one digit; e.g..
May 22, 1981 = 05/22/81. Enter month and year of next appointment for children three
years of age and older.
RESPONSIBLE PERSON/PATIENT ADDRESS: When the patient is under 18 years of age and
not an emancipated minor, enter name, street address, city, and ZIP code of parent,
guardian, or foster parent with whom the patient lives.
ETHNIC CODE: Enter appropriate code number. If patient's ethnicity is not included in
the codes provided, or if ethnicity is unknown, enter code 7 ("Other"). See page 54 for
list which differentiates Pacific Islanders from other Asian groups.
MEDICAL RECORD NUMBER: (Optional) Use this space to enter patient record or
patient account number assigned by the provider.
DATE OF SERVICE
DATE OF SERVICE: Enter the date of CHDP service. Use O's when entering dates of only one digit,
e.g.. May 1, 1979 = 05/01/79. (See Example 3.) If procedures were performed on different days,
enter the date of the HISTORY and PHYSICAL EXAM. If the child is a Medi-Cal patient, the month
and year of the "Date of Service" should be the same as the month and year on the Medi-Cal
POE label, if attached.
EXAMPLE 3
CHDP ASSESSMENT | so |i | Bireion | gy fr Uo
NT PROBLEM | INDICATED, Appropriate Column 03] 0: / | q. 0
Indicate outcome od each SUSPECTED | a NEW | KNOWN r
screening procedure De ATL YE Vo D i
EXAMPLE 4
CLAIM CONTROL NUMBER « FOR STATE USE ONLY |
: | STAPLE
30 %OT STAPLE | HERE
N BAR AREA . i
Ee — :
’ De Ee FIRST UNLETIAL) Tan A ( ) | MEDICAL RECORD NO CR Code |
D ANE \/
ceem| PATIENTS COUNTY OF RESIDENCE TELEPHONE NUMBER
SiIRTHDAT AGE is NEAT VISIT : bi Aan
av [] a < san
OA | iz gn 3 3 (JS SperAMENT 34555272 631" 19 ae 18
NSIBLE PERSQN NAME) (STREET (CITY) Sri Ho same
¥i Doc 1784 Fim STageT ~Sherameno it7r4 BE ie
BS PTET OFS KZ FOLLOW UP CODES
CCNIRA CHDP ASSESSMENT | | — Sh, isa Cassin 430, 40 L 4 SLA oan) OR NOW 4. ot EET iNc/REruRY VISIT
Indicate outcome for each | susecren | VO! NEW | KNOWN | L QUESTIONABLE RESULT. RECHECK sEreRve T0 ANOTHER EXAMINER
screening procedure NEEDED ah FEES SCHEDULED
LA 8 | € | 1 51 MADE Ano a1 STARTED 5 EO REEUSED
| | | Hi 10 7 TELEPHONE NU'ABE=
01 HISTORY ana PHYSICAL £XAM | i / | 1.30.95 HaroLo ati ht 1234
22 DENTAL ASSESSMENT REFERRAL | i 9 | REFZRRED TO TELEPHONE “it, 1862
33 NUTRITIONAL ASSESSMENT | | | 4
3a NTIIPATORY COIANCE id | | Eh don
05 DEVELOPMENTAL ASSESSMENT! Yr | | | ! If A PROBLEM IS DIAGNOSED THIS VISIT PLEASE ENTER
06 SNELLEN OR EQUIVALENT iV | jos #00 | YOUR DIAGNOSIS IN THIS AREA
07 AUDIOMETRIC vi. 5 7 ond
38 HEMOGLOBIN OR HEMATOCRIT ) x 3,0/ o/ Orrrrs corn -(3)
)3 URINE DIPSTICK vv: . | og i H [ur mul /)
10 COMPLETE URINALYSIS | {10 of HY | EART (
11 TB MULTIPUNCTURE v7 Fu |
. ”
12 TB MANTOUX Vv | | {2 YQ i 03 O1eT1A2Y Couns ¢ LING
|_JTMERTESTS | SEE CODES ON REVERSE SIDE OF LAST PAGE | cooe| amwer tests J
022.70 |
5 £1000 Liao | v_ | i
|
| |
| i
|
By
Qzven (3)
02 Dentar Carrés (5)
)
A M HEIGHT | WEIGHT 6 is)
Z = “G8 = Fo ’ BIRTH WEIGHT Of HVEMIP (3)
© 3IVEN “ODA | NOT GIVEN TODAY
NE rr SR ERA] it “hun RAD | ¥ ICO 9 CODES
IMMUNIZATIONS | CATE Pp! up! ) | | LE 1
“CR 1¢ FOR SATE FOR | CONTRA. | i
3 ,
SEC al GE NOICAED | q 2 ] 7 1 A :
: | 3 C og ul 9 00 y AD I od / J Oo
31 POLIO - ORAL {We ty THE QUESTIONS BELOW
32 OPT Di/Ta WARE - MUST BE ANSWERED
33 fo MURFE war | i fy 13 . 1. Patient 1s Exposed to Passive (Second Yes{3. No X
38 Hib CV | |v’ In Hand) Tobacco Smoke. Tr
| i | 2. Tobacco Used by Patient Yes. NoXX
| |
| 3. Counseled About/Referred Far Yes NokJ
PATIENT.VISIT 1x7 | TYPE OF SCREEN ( | TOTAL FEES Tobacco Use Prevention/
[7] Mew Paver {
| rn Vn | ina | Routine rst i XlLe7. 1 Cessation.
PROVIDER OF SERVICE: Name. Acaress.
leseonone Number (Please include Area Coded
XX NUMBER 23 fa! § 5 |
Enrolled in WIC xX Referred to WIC
NOTE: WIC requires Ht.. Wt. and HG3/HCT
NN STrywé ik MO
To Ax Yak REET
CR a 95514
SITE OF SERVICE IF OTHER THAN ABOVE:
[Hd PARTIAL SCREEN IB PROCEDURE RECHECK
ACCOMPANIES PRIOR PM 160 DATED | |
PATIENT
ELIGIBILITY
This 1s to cernfy that the screening information is true and complete. and the resvits explained to
the chiid or bis parent or guardian. | understand that payment ond sahsfaction of this cloim moy
be Irom Federal or State funds, and that any foise cloims, statements ar documents ar conceai- v
ment of @ material fact, moy be prosecutec under apoiicable Federal or Stote law. | ciso cernfy|
thot e of the services biled on this form hove been or wil be biiled to Medi-Cal. the
34) 34 5 Gb 0) 5b | |
If covered by Mem<Cal. ester Medr-Cal 1.0. number above AND attach PO €. abet
Vv thaded area delow
Patient not on Medvlal Prreat or guardian Kas 1636 and Signed ehigibihity statement
SIGN AR JRE OF Owing R
gi groan : : # LL {
Pi ip,
#9 3/1/90
CONFIDENTIAL SCREENING/BILLING REPORT Copy |
STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
- MAIL TO MEDI-CAL CHOP I 12
Medi Cal, CHDP
PO Box 15300
Sacramento. CA 25351 12)
COMPLETE HEALTH ASSESSMENT
CHDP ASSESSMENT SECTION
(See Example 4)
This section is used to record the screening procedures performed and the outcomes of these
procedures. SCREENING PROCEDURES APPROPRIATE TO A PATIENT'S AGE AND SEX ARE LISTED ON
THE TABLE "HEALTH ASSESSMENT PROCEDURES REQUIRED FOR VARIOUS AGE GROUPS," page 50.
(See the CHDP Medical Guidelines for further criteria for using these tests.)
SCREENING PROCEDURES: Screening Procedures with their corresponding codes are:
CODE SCREENING PROCEDURES
01 History and Physical Exam
02 Dental Assessment/Referral
Medi-Cal eligible children three (3) years of
age and older must be referred to a dentist if
not currently under care.
03 Nutritional Assessment
04 Anticipatory Guidance/Health Education
05 Developmental Assessment
06 Visual Acuity
Snellen or Equivalent
07 Audiometric
08 Hemoglobin or Hematocrit
09 Urine Dipstick
10 Complete Urinalysis
11 TB: Multipuncture
12 TB: Mantoux
OTHER TESTS (See reverse side of the last copy of
the PM 160)
13 Sickle Cell: Electrophoresis — Will be
reimbursed once and only if the child is both a
member of a high risk group and anemic, i.e.,
Hemoglobin of less than 11 grams of
Hematocrit of 34% or less.
14 lead: FEP — Should be done if health history
warrants or prior approval received from State.
15 Lead: Blood Lead
16 VDRL, RPR, or ART
17 G.C. Culture: To be done when social/sexual
history indicates appropriate.
18 Pap Smear: To be done beginning at age 17
or younger if sexually active.
19 PKU: Blood Test — Reimbursable only if done as
a repeat on infants under one month of age
who were first tested in the hospital at under
24 hours of age.
; To be done at age 13 or
2 h It
0 Chlamydia Culture { (ye, if indicated.
21 Pelvic Examination
When providing tests coded 13 through 21, enter the Test Code and the name of the test
in the spaces provided in the box "OTHER TEST NAMES."
ASSESSMENT PROCEDURE OUTCOME COLUMNS are the columns headed: NO PROBLEM
SUSPECTED—(A); REFUSED. CONTRAINDICATED, NOT NEEDED —(B); AND PROBLEM
SUSPECTED—(C& D).
by the examiner.
(See Example 5) OUTCOMES and COMMENTS should always be entered
Entries are made in the Assessment Outcome Columns for every procedure 01 through 12 and
for ‘Other Tests" when done as follows:
Column A —
Column B ee
NO PROBLEM SUSPECTED: Enter a check mark (Vv) in this column if the
procedure is performed and no problem is suspected, or a child three
years of age or older is under appropriate dental care.
REFUSED, CONTRAINDICATED, NOT NEEDED: Do not mark Column B
(Refused, Contraindicated, Not needed) when laboratory tests are done
outside of provider's office. Enter results of tests even though no fee is
charged to CHDP.
Enter a check mark (Vv) in this column when:
REFUSED: The patient or responsible person refused the procedure for any
reason, ofr the patient is unable to cooperate in a procedure where the
provider attempted to obtain a specimen or perform a procedure. It is
also considered a refusal of a test when the patient/family does not call
back or return for a reading of a tuberculin test.
or
CONTRAINDICATED: The procedure is deemed medically inappropriate.
or
NOT NEEDED: The test is not appropriate for patient's age, or the test was
recently done.
An explanation must be entered in the "COMMENTS/PROBLEMS" area
when the test appropriate for the child's age according to the "Health
Assessment Procedures Required for Various Age Groups" table was not
given.
NOTE: No payment will be made for a procedure when outcome Column B is checked. The
only exception is a tuberculin test which has been given but the provider cannot
obtain a reading.
Columns C & D — PROBLEM SUSPECTED: Determine if the problem is "NEW" or "KNOWN" to
the family.
Enter the Follow-Up Code NUMBER for the Follow-up Activity in the
appropriate column. DO NOT USE CHECK MARKS (V).
See Example 6 and Instructions which follow.
EXAMPLE 5
REFUSED PROBLEM SUSPECTED
Enter Follow Up Code
CHDP ASSESSMENT | cop, | woenteo. | spproprine column
Indicate outcome for each suseecten | MOET NEw | known
screening procedure JA JB c D
01 HISTORY and PHYSICAL EXAM
/
02 DENTAL ASSESSMENT/REFERRAL
03 NUTRITIONAL ASSESSMENT
04 ANTICIPATORY GUIDANCE
HEALTH EDUCATION
05 DEVELOPMENTAL ASSESSMENT
06 SNELLEN OR EQUIVALENT
07 AUDIOMETRIC
08 HEMOGLOBIN OR HEMATOCRIT
09 URINE DIPSTICK
10 COMPLETE URINALYSIS
11 TB MULTIPUNCTURE
12 TB MANTOUX
CODE OTHER TESTS | SEE CODES
Ia BLooo LEAD
Vv’
=
v_
REVERSE SIDE OF LAST
N
N
N
R
PAGE oO
N
A
EXAMPLE 6
£5 4 | Refusep | PROBLEM SUSPECTED DATE OF SERVICE FOLLOW UP CODES
NO CONFa4 INDICATED OR NOW 4. DX PENDING/RETURN VIS
C H D P ASSESS M ENT PROBLEM | 'NDICATED. Approprate Column 2 J] q0 L 3) Sal Mo L SCHEDULED
Indicate outcome for each susPECTED | et | NEW | KNOWN 2 QUESTIONABLE RESULT. RECHECK 5 REFERRED T0 ANOTHER EXAMIN
screening procedure NEEDED FEES SCHEDULED FOR DX/RX
vA vB C 0 3. DX MADE AND RX STARTED 6. REFERRAL REFUSED
01 HISTORY and PHYSICAL EXAM | 3] /
02 DENTAL ASSESSMENT/REFERRAL | 12
03 NUTRITIONAL ASSESSMENT icf 14
TORY GUIDANC
04 EAL TH EDUCATION Nee Vv
05 DEVELOPMENTAL ASSESSMENT| / |
06 SNELLEN OR EQUIVALENT v_ |
07 AUDIOMETRIC Vv. | [
08 HEMOGLOBIN OR HEMATOCRIT i | 3
09 URINE DIPSTICK 'v |
1C COMPLETE URINALYSIS Vv, | i
11 TB MULTIPUNCTURE Fv
12 TB MANTOUX Vv | |
CODE OTHER TESTS | SEE CODES ON REVERSE SIDE OF LAST PAGE
1X __1BLood L.ERC| |
10+
; [}
1
A
:
FOLLOW-UP CODES FOR USE IN COLUMNS C AND D (See Example 6, on Previous Page).
I NO DX/RX INDICATED OR NOW UNDER CARE: Enter Code 1 if no treatment is indicated or
the patient is now under care, e.g., dental problem now under care.
2 QUESTIONABLE RESULT. RECHECK SCHEDULED: Enter Code 2 if fhe accuracy of a test result is
questionable. Use ONLY for screening procedures 06 through 20. A fee may be entered for
this screening procedure.
3. DX MADE AND RX STARTED: Enter Code 3 if diagnosis and treatment of a problem are
started on this visit. Enter the diagnosis and the appropriate ICD-9 Code in the
"COMMENTS/PROBLEMS" area.*
4. DX PENDING/RETURN VISIT SCHEDULED: Enter Code 4 if:
a. A return visit has been scheduled for diagnosis, of
b. A return visit has been scheduled for diagnosis and treatment, or
c. A return visit has been scheduled for treatment only. In this instance, enter the
diagnosis and the appropriate ICD-9 Code in the "COMMENTS/PROBLEMS" area.”
5. REFERRED TO ANOTHER EXAMINER FOR DX/RX: Enter Code Sif:
a. The patient has been referred to another provider for diagnosis and treatment. Enter
the name and telephone number of the other provider in the designated shaded
areaq.
b. A diagnosis has been made today and the patient has been referred to another
provider for treatment. Enter the diagnosis and the appropriate ICD-9 Code in the
"COMMENTS/PROBLEMS" area* Enter the name and telephone number of the other
provider in the designated shaded area.
c. When a dental problem is suspected, enter the name and telephone number of the
dentist in the designated shaded area.
6. REFERRAL REFUSED: Enter Code 6 if the patient or the responsible person has refused refernal
or follow-up by examiner for any reason, including inability to pay (if the patient is not
covered by Medi-Cal).
NOTE: CHDP DOES NOT PAY FOR DIAGNOSIS AND/OR TREATMENT SERVICES.
IF THE PATIENT IS MEDI-CAL ELIGIBLE, BILL THE MEDI-CAL FISCAL INTERMEDIARY FOR
MEDI-CAL COVERED DIAGNOSIS AND TREATMENT SERVICES.
* See page 58 for the list of most commonly used ICD-9 Codes for children.
“11.
GENERAL INSTRUCTIONS:
. Every screening Procedure must have either a check mark (Vv) in Column A or B OR a
Follow-Up Code in Column C and/or D.
. DO NOT enter check marks (V) in both Columns A and B for the same procedure.
«+ DO NOT enter check marks (V) in Columns C or D.
. DO NOT enter check marks (V) in Columns A or B AND enter a Follow-Up Code in Column C
and/or D for the same procedure.
. A Follow-Up Code may be entered in both Columns C and D for a single screening
procedure if that procedure reveals both a new problem and the recurrence of an old
problem.
. For Screening Procedure 01, "History and Physical Examination,” up to two Follow-Up Codes
may be entered in Column C and/or up to two Follow-Up Codes may be entered in
Column D. (See Example 6.)
OTHER TESTS: When an "OTHER TEST" is given (Codes 13 through 21): (See Example 7)
. Enter the Test Code number and name of the test (as listed on page 8).
. Enter either a check mark (v) in Outcome Column A OR an appropriate Follow-Up Code in
Outcome Column C and/or D.
. Do not enter a check mark (v) in Other Tests’ Outcome Columns unless other tests are
given.
EXAMPLE 7
CODE OTHER TESTS | SEE CODES ON REVERSE SIDE OF LAST PAGE COOE| OTHER TESTS
15 1Bloco léro | V
“¥2.
HEIGHT, WEIGHT, BLOOD PRESSURE, HEMOGLOBIN/HEMATOCRIT: (See Example 8A and 8B.)
AMERICAN SYSTEM
(Check Box A)
Height/Length
Weight
When measuring and recording height/length and weight, use either the
Metric (kilograms and centimeters) or the American (pounds and inches)
system.
If using the American system, check the box marked "A." If using the
metric system, check the box marked "M."
Fill all spaces. Use zeros if necessary. (See examples below)
Measure the recumbent length of all infants less than 25 months of age:
measure the height of other individuals.
Record to nearest 1/4 inch. Enter zero in the first space. Enter whole
inches in spaces 2 and 3. Convert all fractions of an inch to fourths and
record fraction in the last space as follows:
If no fraction enter 0
If 1/4 inch enter 1
If 2/4 inch enter 2
If 3/4 inch enter 3
Example: If height is 30 inches and no fraction, record as follows:
inches fourths of inch
Example: If height is 45 1/2 inches, record 45 2/4 as follows:
S
E
10/4152
So TALS
inches fourths of inch
Record in pounds and ounces to the nearest ounce. Enter zero in first
space for weight less than 100 pounds. Use last two spaces for ounces.
Enter zeros when there are no ounces.
Example: If weight is 46 pounds and no ounces, record as follows:
0141610] 0)
IO Lp a
pounds ounces
Example: If weight is 16 pounds and 6 ounces, record as follows:
Lo, to 06)
Ae
pounds ounces
Example: If weight is 125 pounds and no ounces, record as follows:
Li, 215 0:0]
ae
pounds ounces
Birth Weight Enter birth weight, (if known) for children up to two years of age.
Enter pounds and ounces, and follow above directions.
If parent reports birth weight in grams, convert to pounds and ounces, if
possible
METRIC SYSTEM
(Check Box M)
Height/Length Record to nearest 0.1 centimeter.
Enter zero in the first space when height is less than 100 centimeters. Use
last space for tenths of a centimeter. If no tenths of a centimeter, enter
zero.
Example: If height is 49 centimeters, record as follows:
lop ay 9; ol
eS
centimeters tenths of centimeters
Example: If height is 92.3 centimeters, record as follows:
Loi91 2:3 ag
centimeters tenths of centimeter
Example: If height is 156.0 centimeters record as follows:
115.60
CB
centimeters tenths of centimeter
Weight
Birth Weight
Record to the nearest 0.1 kilogram.
Enter zeros in first two spaces if weight is less than 100 kilograms. Use last
space for tenths of a kilogram. Enter zero in the last space if no tenths of
a kilogram.
Example: If weight is 26.2 kilograms, record as follows:
10,02 6,2]
a]
kilograms tenths of kilogram
Example: If weight is 45.0 kilograms, record as follows:
l0o,0,4,5,0
if KS
Kilograms tenths of kilogram
Example: If weight is 102.3 kilograms, records as follows:
Farti os, 3
ok)
Kilograms tenths of kilogram
Enter birth weight, (if known) for children up to two years of age.
Use kilograms and follow above directions. If birth weight is known in
grams, convert to kilograms by moving the decimal point three spaces to
the left. Round to the nearest tenths.
Example: If birth weight was 3523 grams, enter 3.5 kilograms and record
as follows:
Loo, 3,5]
Example: If birth weight was 3573 grams, enter 3.6 kilograms and record
as follows:
01:0) 316
If parent reports birth weight in pounds and ounces, convert to Metric, if
possible by dividing birth weight by 2.2.
Example: If birth weight is 9 pounds, divide 9 by 2.2 = 4.1 kilograms or 4100
grams.
Example: If birth weight is 9 pounds, 8 ounces, divide 9.5 (8/16 or 1/2
pound) by 2.2 = 4.3 kilograms or 4300 grams.
he
BLOOD PRESSURE: Record Systolic/Diastolic on all children three (3) years of age or older.
HEMOGLOBIN: Record to the nearest 0.1 gram.
HEMATOCRIT: Record to the nearest 1 percent.
EXAMPLE 8A
HEIGHT WEIGHT BLCOD PRESSURE
0i3:6:210:.28:0:3 98 /20
HGB HCT. BIRTH WEIGHT
(4 _10v6:0:%
EXAMPLE 8B
HEIGHT WEIGHT BLOOD PRESSURE
194 8120113258 / 10
HCT BIRTH WEIGHT
0: 3.5 0:.0:2;9
REFERRED TO: (See Example 9.) When referrals are made to other providers, enter the Screening
Procedure Code(s) relative to the referral, and the name and telephone number of the other
provider (when this information is available). If the patient is referred to more than two other
providers, enter the appropriate codes, provider names, and telephone numbers in the
"COMMENTS/PROBLEMS" area.
EXAMPLE 9
REFERRED TO. TELEPHONE NUMBE=
ARO LD Fon 163s Of 56 1234
REFERRED TO: TELEPHONE NUMBER
——
—
IMMUNIZATIONS: The patient's Immunization Record is to be assessed and updated at every
CHDP Complete Health Assessment and at every Partial Screen if immunizations are given.
Provide the parent or patient with the California Immunization Record (yellow card) as the
patient's permanent record of immunizations. See page 46 for Recommended Immunization
Schedule. See back of the Parent Copy of the PM 160 for additional reimbursable
immunizations.
Enter a check mark (v) in only one of the Outcome Columns headed A, B, C, or D for each
immunization. (See Example 10.) If the entire immunization section is not completed, a Provider
Correction Request (PCR) form will be sent 10 the provider.
NOTE: For children under 2 months of age, immunizations need not be assessed at all and
for children under 15 months of age Measles, Mumps, and Rubella need not be
assessed. For children under 18 months of age or over 6 years of age Hib CV need
not be assessed.
Determine if an immunization is to be GIVEN TODAY or NOT GIVEN TODAY. (See Example 10)
If immunization is GIVEN TODAY: Enter a check mark (v) in either:
Column A — Now Up-to-Date for Age: The immunization given today brings the
patient up-do-date for age, OR
Column B — Still not Up-to-Date for Age: The immunization given today does not bring
the patient up-to-date for age.
If immunization is NOT GIVEN TODAY: Enter a check mark (V) in either:
Column C — Already Up-to-Date for Age: The immunization status is current or the
patient has had the disease, OR
Column D — Refused or Contraindicated: The patient or responsible person refuses
needed immunization; the administration of a needed dose is medically
contraindicated or deemed inappropriate.
Example 10
GIVEN TODAY | NOT GIVEN TODAY
NOW U STILL NOT ALREADY REFUSED
IHMUNIZATIONS CT | oe | oR | olf
AGE AGE AGE INDICATED
A B C D
31 POLIO - ORAL |31
33MMR®” MuR[R MR[P Va 33 :
38 Hib CV Vd 38 7
37 7Py va 7 13.97
NOTE: There must be a minimum interval of six (6) weeks between doses of Oral Polio and a
minimum interval of four (4) weeks between doses of DTP, DT, Td, or IPV.
217.
when Inactivated Trivalent Poliovirus Vaccine (Salk) is given.
page)
(See Example 10, on previous
. Enter Code 39, IPV, and a check mark (v) in either Column A or B on one of the blank lines.
. Enter a check mark (Vv) in Column D on line 31 for Polio-Oral.
SPECIAL INSTRUCTIONS FOR MEASLES, MUMPS, AND RUBELLA VACCINES
When Measles, Mumps, and Rubella are assessed or given as a TRIPLE COMBINATION: (See
Example 11.)
. Check (Vv) square number 1 (MMR) on line 33, and
. Check (V) the appropriate Outcome Column for line 33.
NOTE: The MMR combination should always be used for initial immunization of children at
age 15 months unless there is a specific indication to do so earlier.
When a second MMR is given, a comment must be entered in the
"COMMENTS/PROBLEMS" area.
Individual doses of Measles, Mumps, and Rubella vaccine WILL NOT be reimbursed
unless valid reasons are provided in the "COMMENTS/PROBLEMS" area.
EXAMPLE 11
GIVEN TODAY NOT GIVEN TODAY
IMMUNIZATIONS Na | Sh | MEY | MERE
FOR DATE FOR | DATEFOR | CONTRA
AGE AGE AGE INDICATED
A/S B c D
31 POLIO - ORAL Vv “ [0.50
32 OPT DU/Td V. 2 (p.7Y
I3MMRE MuR(R MRF | B28 63
38 Hib CV WLLL
WHEN MEASLES, MUMPS, AND RUBELLA ARE ASSESSED OR GIVEN IN A COMBINATION OTHER THAN
MMR: (See reverse side of parent copy of PM 160 for appropriate codes.)
MUR Combination With Measles As A Single Item: (See Example 12.)
. Check (V) square number 2 (MuR) on line 33;
. Check (V) the appropriate Outcome Column for line 33; and
. Enter Code "34" and "Measles" and check (V) appropriate outcome column on one of the
blank lines.
EXAMPLE 12
GIVEN TODAY | NOT GIVEN TODAY
TE | or | ar =e |
IMMUNIZATIONS FOR OATE FOR | DATE FOR | CONTRA-
AGE AGE AGE INDICATED
A B Cc D
31 POLIO - ORAL v’; 3
32 DPT Dt/Td Vv 32
-r
33MMRC) MuRME MRCP | Vf nl3, 45
38 Hib CV Vv 18 ]
34 iu ERSLES Vv" |
|
MR Combination With Mumps As A Single Item: (See Example 13.)
. Check (V) square numbered 3 (MR) on line 33;
. Check (V) appropriate Outcome Column on line 33: ond
. Enter Code "35" and "Mumps" and check (V) the appropriate Outcome Column on one of
the blank lines.
EXAMPLE 13
GIVEN TODAY | NOT GIVEN TODAY
IMMUNIZAT eae | Uri | Ae | or
IONS FOR DATE FOR DATE FOR CONTRA-
AGE AGE AGE INDICATED
A B C D
31 POLIO - ORAL v7 a
32 DPT DU/Td i ZZ =
33MMR( MuwR( RE MRXE | VV 22/47
38 Hib CV _ We 5
28 1 MPS Vv:
When either Measles, Mumps, or Rubella are given as a separate immunization: (See
Example 14.)
Enter the code and the name of the vaccine given and check (Vv) the appropriate
Outcome Column on one of the blank lines, and
Check (V) the appropriate square and Outcome Column on line 33 for the two vaccines
not given.
EXAMPLE 14
a GIVEN TODAY | NOT GIVEN TODAY
IMMUNIZATIONS FOR DATE FOR | DATE FOR | CONTRA-
AGE AGE INDICATED i
A 5 Cc D
31 POLIO - ORAL Sa 31
32 DPT Dt/Td vv 2
33MMR(T Mur MRP vy 3
38 Hib CV v. 3
J4 [M)epslés v_ 34 [6.37
-20-
.
ral
|
|
H
PATIENT VISIT/TYPE OF SCREEN
PATIENT VISIT: (See Example 15.) The time invested is the determining factor.
1— NEW PATIENT OR EXTENDED VISIT:
a. New Patient: Enter check mark (v) if the patient has not previously received a CHDP
Health Assessment by this provider, and no CHDP Health Assessment record is
established with this provider.
b. Extended Visit: Enter a check mark (V) if the patient requires as much or more time to
be assessed as does a new patient.
When claiming for an extended visit for patients assessed within the last two years,
providers must indicate the reason in the "COMMENTS/PROBLEMS" section of the
PM 160.
2— ROUTINE VISIT: Enter a check mark (V) if the patient's visit is a routine return visit and the visit
requires less time than ordinarily needed with a new patient or an extended visit.
TYPE OF SCREEN: (SEE EXAMPLE 15.)
1— INITIAL: Enter a check mark (V) if this is, to the best of your knowledge, the first time patient
has received CHDP Health Assessments and tests by ANY provider.
2— PERIODIC: Enter a check mark (V) if the patient has received CHDP Health Assessments
and tests before by ANY provider.
EXAMPLE 15
PATIENT VISIT (V) : “TYPE OF SCREEN (V)
| / N..
Nes pnae 2] Routine Vist ts Pesiodic
Vi i OH
FEES: The History and Physical Examination may be reimbursed up to the CHDP Schedule of
Maximum Allowances (see page 52). Reimbursement for other screening procedures and
immunizations will be either the provider's usual charge or the amount specified in the CHDP
Schedule of Maximum Allowances, whichever is less.
When a provider uses vaccines provided at no cost by the State Immunization Assistance
Program, the provider shall bill the vaccine administration fee specified in the CHDP Schedule of
Maximum Allowances.
If a laboratory test is performed by other than the screening provider, the provider may bill for
the charge made to the provider by the laboratory plus a charge in the amount specified in the
CHDP Schedule of Maximum Allowances for the provider's collection and handling of the
specimen. This total shall not exceed the Maximum Allowance specified for the laboratory test.
Based on the reimbursement schedules, enter the appropriate fee for each completed
procedure or immunization. Be sure the fee is entered on the line which matches the Screening
Procedure and/or Immunization Codes being billed.
Fees for "OTHER TESTS" must include the Procedure Code and the appropriate fee.
Fees for immunizations not preprinted on the form must include the appropriate code with the
appropriate fee.
TOTAL FEES: Add fees and enter total amount. (See Example 16.)
EXAMPLE 16
| REFUSED PROBLEM | SUSPECTED SATE OF SERVICE
CHDP ASSESSMENT | o. | Bk | Sees | £9 5)
Indicate outcome for each
; NOT ; SUSPECTED | eonen NEW | KNOWN
screening procedure LA adc He FEES
| | ! |
01 HISTORY and PHYSICAL EXAM 3 | / | | 3D. 95
02 DENTAL ASSESSMENT/REFERRAL | 5] |
03 NUTRITIONAL ASSESSMENT | GR
04 BGR ERATION iv, | i
05 DEVELOPMENTAL ASSESSMENT! 7 | | 1 ’
06 SNELLEN OR EQUIVALENT YY, | | | x A 00 i
07 AUDIOMETRIC Pv v7 Ged
08 HEMOGLOBIN OR HEMATOCRIT | a 18 3.0)
99 URINE DIPSTICK v’ 129
10 COMPLETE URINALYSIS vo | EK
11 TB MULTIPUNCTURE | LV In
12 TB MANTOUX vv | | liz 7, £3
coe 1 OTHER TESTS SEE CODES ON REVERSE SIDE OF LAST PAGE CODE | OTHER TESTS ,
BB Dpo0 [tho |V | g122. $5
L
© 8 [0362102903970 |
6.7% |
GIVEN TODAY NOT GIVEN TODAY
ET Ta! 2 | IMMUNIZATIONS FOR SAE oR | oATEFoR | coves. |
AGE GE | NOICHTED |
A 8 c 0
31 POLIO - ORAL Vv’ 3
32 OPT DW/Td Vv 2 |
33MMRTY MuR2 MRCS Vv’ | 13 |
_38HibCV Vl 38 I
Vv
|
PATIENT VISIT (v)
|
| | |
TYPE OF SCREEN (y, | TOTALFEES |
IFT RR, d—— [= AF [FTC
.22.
» :
? {
: }
{
SHARE OF COST (See Example 17.)
When Medi-Cal eligible patients/families have a share of cost (SOC), the cost of the CHDP
health assessment may be applied to this SOC (see Provider Manual). The patient must be
billed for that SOC applied to the CHDP health assessment fee. If the SOC is less than the total
CHDP fee, the remainder of the fee may be billed to CHDP by:
. Entering the "usual fee(s)."
. Subtracting the "Share of Cost" amount from the “usual fees," starting with the "History and
Physical Exam," by drawing a line through the usual fee(s) and entering the amount(s)
remaining;
. Totaling the amounts remaining after the "Share of Cost" has been subtracted; and
. Entering the "Share of Cost" amount in the "COMMENTS/PROBLEMS" section.
The patient's COUNTY IDENTIFICATION or SOCIAL SECURITY NUMBER and CHECK DIGIT must be
entered on this PM 160 in the usual location prior to submitting the PM 160 for payment.
EXAMPLE 17
DATE OF SERVI E FOLLOW UP CODES
WK J) 75 1. NO DX/RX INDICATED OR NOW 4. OX PENDING/RETURN VISIT
> ER at RESULT, RECHECK &§ Jneduiio S. REFERRED TO ANOTHER ¢
FEES SCHEDULED FOR DX/RX IR fanaeg
3. DX MADE AND RX STARTED 6. REFERRAL REFUSED
REFERRED TO. TELEPHONE NUMBES
BS i {
REFERRED TO TELEPHONE NUMBE?=
COMMENTS/PROBLEMS
J IF A PROBLEM IS DIAGNOSED THIS VISIT. PLEASE INTER
| 0 b-G-6 YOUR DIAGNOSIS iN THIS AREA
vd] Hg 26:0) ’ Y; Tn 3.00 SHARE [2 OST 50.00
| 09 |
3 HA 54}
| 1
in 7153
| CODE| OTHER TESTS
|
i I ICO S CODES
| 1 | 2 To 3
| i ii
| { vid i
3 , A ( : Le By ! THE QUESTIONS BELOW
2 /e, MUST BE ANSWERED
3
L. Patient 1s Exposed to Passiy e (Second 38 Hand) Tobacco Smoke. i 3 MTR
2. Tobacco Used by Patient Yes 3 Noi
3. Counseled About/Referr ed For Yes ' TOTAL FEES Tobacco Use Prevention/ os vo X
P Cessation.
-93.
PROVIDER OF SERVICE: Enter provider's name; address; telephone number, (including area
code); and provider number.* (See Example 18.)
PROVIDER NUMBER: Enter Medi-Cal provider number. If not a Medi-Cal provider, enter
provider number assigned by the local CHDP program. The provider number must be
accurate and legible because claims are automatically paid to the provider number listed
on the PM 160.
SITE OF SERVICE IF OTHER THAN ABOVE: Enter site of service if given at an address other
than address given for the provider.
SIGNATURE OF PROVIDER: It is required that every PM 160 be signed and dated by the
provider or a designated representative. Do not use a signature stamp.
EXAMPLE 18
PROVIDER OF SERVICE: Name, Address, PROVIDER KUMBER
Telep ¢ Number (Please Include Area Code] ; XX: Ys 10, 305
lo FINN STaywELL P.O
“55 [VAIN STREET
Gaceaminto, (La. 956814
SITE OF SERVICE IF OTHER THAN ABOVE:
This is to certify that the screening information is true and complete, ond the results explained to
the child or his parent or guardion. | understand that payment and satisfaction of this claim may
be from Federal or State funds, and that cny false claims, statements or documents or conceal-
ment of a material fact, may be prosecuted under applicable Federal or State law. | also certify
that none of the services billed on this form have been or will be billed to Medi-Cal, the|
patient, or other insurance proyiders.
Up (pi. oft (UY afr [Ge
] Se. DATE SIGNATMRE OF PROVIDER
* Notify the local CHDP program immediately of any change in provider information.
«Oh
COMMENTS/PROBLEMS: (See Example 19.) Please use this space for any remarks which can
clanfy the results of the health assessment and to communicate to the local and State CHDP
Programs. For example:
a.
b.
Enter a diagnosis and its appropriate ICD-9 Code if itis made this visit.
Briefly explain all suspected problems, e.g., nature of dental problem.
Indicate whether a child three years of age or older is now receiving dental care of when
last care was received.
Write a brief explanation when a procedure is not performed for any reason other than not
appropriate for age.
Record the Screening Procedure Code and the name and telephone number of the
referred provider when more than two referrals are made.
Indicate the reason for the extra time spent with the patient when claiming for an
‘Extended Visit" for other than new patients or patients not assessed for two years.
Enter an acceptable explanation of the need for an extra assessment when claiming
health assessments at more closely spaced intervals than are indicated on the CHDP
Periodic Appointment Schedule. For further inforrnation, see "Billing Restrictions” in the
Provider Manual.
Enter the head circumference measurement on children one year of age and under.
Enter results of vision test.
Indicate when TB test given, but patient did not return for reading.
Note any discrepancies with information on POE label.
Indicate when using mother's POE label for new infant.
Enter comment when a single dose of Measles, Mumps, or Rubella vaccines is given and
when a second MMR immunization is given.
EXAMPLE 19
CLAIM CONTROL NUMBER » FOR STATE 1JSE ONLY
SC w0l STAPLE
N BAR AREA
(FIRST UNITIAL) p [3 OF Jan e A MEDICAL RECORD NO
\7723Y3 e777
LA. Code
oe cme PATIENT'S COUNTY OF RESIDENCE
an ALRAME NTO _
CODE |
341555212 03]
TELEPHONE NUMBER NEXT VISIT AMencan in
2 Asian
1 Blacn
w
127! coe
= Zs 97 3 0
1784 Fim Stag
: my PERS, NAME)
| REFUSED PROBLEM SUSPECTED
LT SweramENTO 95814
4 Fiona
S Mes Amer , =.ycanc
6 Wnae
Toner
a Byrn
ALP)
Iz
CONTRA Enter nd Up Lode
CHDP ASSESSMENT | Prowcw | HOGGD | XUN,
hob Laat
FOLLOW UP CODES
L NO OX/RX INDICATED OR NOW 4. DX PENDING/RETURN VISIT
A rooate Columa
Indicate outcome for each Spi woo | ow Ng
FEES
UNDER CARE SCHEDULED
| 2 QUESTIONABLE RESULT. RECHECX S REFERRED TO ANOTHER EXAMINER
| SCHEDULED FOR DX/RX
6. REFERRAL REFUSED
screening procedure |
01 HISTORY ang PHYSICAL EXAM | / | | 030,
DX MADE AND RX STARTED
| TELEPHONE Nu'BE=
95° Fa Pho 165s Off Sb 1134
02 DENTAL ASSESSMENT/REFERRAL !
03 NUTRITIONAL ASSESSMENT {
04 ANTICIPATORY GUIDANCE
FAL TH EDUCATION
REFERRED TO | TELEPHONE NUMBER
COMMENTS/PROBLEMS
06 SNELLEN OR EQUIVALENT 4.00
{F A PROBLEM 1S DIAGNOSED THIS VISIT PLEASE ENTER
YOUR QIAGNOSIS IN THIS AREA
|
|
35 DEVELOPMENTAL ASSESIMENT| i |
1
| 07 AUDIOMETRIC q, 2/
5— 0) Orirrs [cord - (3)
18 HEMOGLOBIN CR HEMATSCRIT Ti og,
09 URINE DIPSTICK ; 3 |
4.57 Heart Murmur (1)
10 COMPLETE URINALYSIS vo | |
i
{
|
|
|
1 TB MULTIPUNCTURE | |
Vv’ | | | | 12
{2 TB MANTOUX |
cog | OMERTESTS | SEE CODES ON REVERSE SIDE OF LAST PAGE | cone
7.33 103 O1e7ary Couns é LING
OTHER TESTS
15 Blood Liao | |
|
10122. +9 |
Le
Gavin (3)
| l | | | 02 DENTAL CrrIés (5)
% 0 0362029039970
{ m HCT
07.5]
! GIVEN TODAY
NO uP | Shit NOt
I. uly
| DAIT 7OR
AGE
i
3
| NOT GIVEN TODAY
Re | REFSED |
hh S08 |
AGE |
¢
IMMUNIZATIONS coy oR. |
NOICATED |
n |
08 HVEMIAR (3)
ICO § CODES
39200172820 Faio0
31 POLIO - ORAL Vv, HRT!
32 0PT Di/Ta | 2
THE QUESTIONS BELOW
MUST BE ANSWERED
Vv
ve {1 33 MMAR! sAuRl
Vv: |»
. Patient 1s Exposed to Passive (Secona Yes
Hand) Tobacco Smoke. 4
No XX
|
. Tobacco Used by Patient Yes 7 No
|
|
i
38 Hib CV |
|
| |
PATIENT VISIT
| New Patent o
TOTAL FEES
. Counseied About/Referred For
Tobacco Use Prevention/
Yes .
fa1ended Yas
|
| |
TYPE OF SCREEN (
| Ye EP A 27. 9 Cessation.
XX 4
XXX
PROVIDER OF SERVICE: Name Acaress
[eseomane Number (Please Incluce Azer Coded 3445 |
Enrotied in WIC ~ X Reiferreg to WIC
NOTE: WIC requires Ht. Wt. and HGB/HCT
Ship we Lh =
w PARTIAL SCREEN © a PROCEDURE RECHECK
| |
ACCOMPANIES PRIOR PM 160 DATED .
NN
Ts Eg RIP REET
os a 95%1¢
3 OF SERVICE if QTHER THAN ABOVE:
This ut to carnly that the screening information if true ond compiete. and the resvils eaproined tol
the child or bus parent or guardian | understand that payment ond satisfaction of this claim may
be Irom Federal or Store funds. and thot any folse ciloims, stotements or documents or conceol- a Ya
ment of a moter fact. may be prosecuted under appiadle Federal or State low. I aiso cernfy]
thot e of the services biled on this torm have Deen or wil be biiled fo Meai-Col, the)
| eLiGiBILINY
|
PATIENT 34) FY ET Go 0) 56
, Ul covered by MeaiCal. enter Mede-Cal 1.0. umber adove AND attach POC ade
V thaded area Deow
V Patient not on MeseCal Parent or guardian Kas rasd and Signed ehidihiy statement
“U0 Td Saget 10 311/90
SICNA PRE OF PaNVI~E3 7 oc LYN 7
CONFIDENTIAL SCREENING/BILLING REPORT
STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
% Meai-Cal/CHOP
COPY 1 - MAIL TO MEDI-CAL CHOP
PO. Box 15300
Sacramento. CA $5851 1200
TOBACCO PREVENTION/CESSATION QUESTIONS
The harmful effects of the use of tobacco products and exposure to secondhand smoke have
been documented. Answers to the following questions must be entered (see pages 56 and 57
for "Protocol for Anti-Tobacco Health Education):
1. Patient is Exposed to Passive (Secondhand) Tobacco Smoke. Yes J No QO
(Is the patient exposed to tobacco smoke at home, day care center, etc.?)
2. Tobacco Used by Patient. Yes QO No Q
(Does the patient use any tobacco products, e.g., cigarettes, chewing tobacco. etc.?)
3. Counseled About/Referred For Tobacco Use Prevention/Cessation. Yes QO NO OO
(Was the patient counseled about tobacco use and exposure and/of referred to a
tobacco use cessation/prevention program?)
Example 20
THE QUESTIONS BELOW
MUST BE ANSWERED
1. Patient is Exposed to Passive (Second YesfJ No[]
Hand) Tobacco Smake.
2. Tobacco Used by Patient Yes] No[]
3. Counseled About/Referred For Yes Xx No []
Tobacco Use Prevention/
Cessation.
97:
ENROLLED IN WIC OR REFERRED TO WIC: (See Example 21.) Infants and children under age
five (5), pregnant women at nutritional or medical risk, and women up to six (6) months
postoartum or breastfeeding an infant under twelve (12) months of age may be eligible for the
women, Infants, and Children (WIC) Supplemental Food Program.
. If the patient is already enrolled in WIC, enter a check mark (v) in Box 1 "Enrolled in WIC."
. If you are making a referral to the WIC Program, enter a check mark (Vv) in Box 2 Referred to
WIC."
WIC requires that height, weight, and hemoglobin/hematocrit values be entered according to
instructions on pages 13—16.
NOTE IN "COMMENTS/PROBLEMS" AREA IF YOU ARE REQUESTING CHDP STAFF TO ASSIST FAMILY
WITH WIC REFERRAL.
Call your local CHDP program if you wish more information about the WIC program.
EXAMPLE 21
[1] Enrolled in WIC Xi Referrec to WIC
NOTE: WIC requires Ht.. Wt. and HG3/HCT
.28-
EXAMPLE 22
deni (88) 119) 1581270017953 1101
J If covered by Medi-Cal, enter Medi-Cal 1.0. aumber above AXD attach P.0.E. label in
shaded ares below.
Vv Patient not on Med Cal Parent o pusrdion bev toed 3 {30 {ed 5lgd eligibility statement.
bo 3 wos 02 :
Example of using patient's
County Identification Number
EXAMPLE 23
PATIENT AID IDENTIFICATION NUMBER : 4
ELIGIBILITY 55 U7 BAsA%67.56 1.) |
!
a If covered by Medi-Cal, enter Medi-Cal 1.D. number above AND attach P.0.E. label in
shaded area below.
: Vv Patient not oa MediLals pea hav reed oto eligibility statement.
HE deces |
Example of using patient's
Social Security Number
na
C ma
:
i NT ELIGIBILITY: “ha CH© 2 airgun ootanig (or is mourned ~agith gssessrant services are in
_CHDP Provider Manual.
MEDI-CAL PATIENT:
CHDP claims wiil only ns paid i S LNG
who are Medi-Cal eligible curing “ne Month nar servi
expedited through the cuto nated svstem, grovice!
claims using current 2roct of 0
submitted without er
resulting delay or denial ©
enty-cne (21) years of age and
2 5 ich To assure PM 160s are
strongly encouraged to submit
O ) ig Medi-Cal card photocopies; claims
r of the ucove may require G manual eligibility check with a
of ©
Providers may bill using zither ing Plents {
SOCIAL SECURITY NUMBER and a CHECK ©}
two digit County Ccde ana wo digit
Examples 22 and 23.)
Y 'CENTIFICATION NUMBER or the patient's
ne nrovider must also enter the patient's
2 for reimbursement to be made. (See
The patient's SOCIAL SECURITY MUMBER ang CHECK DIGIT can be found on the Medi-Cal
card and the POE lapel ne cotent s COUNTY iDENTIFICATION NUMBER can only be found
on the Medi-Cal card. See pares 4Z ond 45 #21 Hiustra tions of a Medi-Cal card issued by
the State and on Imrrsqaiae veeg Meci-Cal cog issuaa oy the county,
Please note that the canants «ounty code is .2caied on the second line of the POE Iabel
on the Medi-Cal carg scuac y 1ve ~ounty ang on he first line of ine POE label on the
Medi-Cal card issued Lv ine Stare.
: Enter the octients two cigii Tounty Coase (county of eligibility or legal residence) in
the first box which is labeled "County.
. Enter the patients two agit Aid Coase in n= sacond box which is iabeled "Aid."
. Enter either tha facial S=ounty umber ang Check Digit or the complete County
identification umpes rnesng Ihe Coun and aid codas) in the box labeled
dentificalion Numoer” Ini® ng Soci! | nouny Nurmoper and Check Digit in the first
ten (10) spaces o ing icennfizarnicn Mumcer Hox. Tnere wil be four (4) blank spaces
at the end of ne 0
. Enter a check mai« Ning CoAT Caen |
. Attach Proof of BE 'cinility (FOF) iacei ior the monn cf seivice in the shaded area. If a
POE Ickel is not oiqiicbie ior ins month of service, securely attach a photocopy of
the Medi-Cal cia ior the menin Sisenice ic ine »M 160.
NOTE: A mother's ?CE labei of Meqi-Cal card nnoiocony may be used for an infant during
the infant's menin cr sinh ang the icllowing moenih.
W
w
we
(97
sa: with their Medi-Cal card A patient evita ios “ring te CALTONGY C7 3MATTENSY
CRF IS NOT canis
-30-
2 NON-MEDI-CAL, STATE-REIMBURSED PATIENTS
a.
NOTE:
Patients who are not Medi-Cal eligible children and not participating in a Head Start
or State Preschool program must meet all of the following criteria to be eligible for a
state-reimbursed health assessment:
(1) The child or young adult is under nineteen (19) years of age;
(2) The child is not enrolled in a Prepaid Health Plan where preventive health services
are a covered benefit; and
(3) The family income from all sources (before taxes) is at or below the income level
specified for the family size.
To determine eligibility:
(1) The parent/guardian or emancipated minor must complete and sign a “Cupp
Eligibility Information" (DHS 4073) form for each patient for each visit. (See page
48.) The provider is not responsible for assuring the accuracy of the information
given. The provider is held responsible for assuring that the parent/guardian or
emancipated minor understands the questions and completes, signs, and dates
the form.
(2) The provider must then review this information and determine whether the
patient is eligible for state-reimbursed services according to the criteria listed
above. For income eligibility, compare the information on the "CHDP Eligibility
Information" (DHS 4073) form with the "CHDP Eligibility Determination Table" which
is distributed to providers by their local CHDP programs.
(3) If the provider determines that the patient is age- and income-eligible, is not on
Medi-Cal, and is not enrolled in a Prepaid Health Plan, the provider should:
« Enter a check mark (V) in box number 2 in the Patient Eligibility area of the
PM 160 (see Example 24); and
« Staple the "CHDP Eligibility Information” form signed by the parent/guardian or
emancipated minor to the back of the PM 160. Staple only on the upper
right side of the claim form.
EXAMPLE 24
PATIENT COUNTY AID IDENTIFICATION NUMBER
i a | | -l | | | | |
It covered by Medi-Cal. enter Medi-Cal 1.0. number above AND attach ?.0.E. ladel
l
| v shaded area below.
[vt Vv Patient not on Medi-Cal Parent or guardian has read and signed eligibility statement.
Patients eligible only for pregnancy or emergency services with their Medi-Cal card
should check the "no" box for Medi-Cal eligibility.
-32 -
EXAMPLE 25
BETTE TTTTICAIM CONTROL NUMBER. + FOR STATE USL otay
: STAPLE
O0 m0! SIAP
{im BAR AREA . ! i HERE
A
P! PAUENT NAME ) (INITIAL) 7 RECORD NO 1 |
{ L.A. Code i
LITLE 0pAY Wor sl
} BIRTHDATE A ("PATIENT'S COUNTY OF RESIDENCE CODE pics £ NUMBER Hexl VISIT | Mien ingan
a”
NIU [018% “i Sz OBeRAMENTO | 341558 A223 |03| ~ | Foto 335,
ir PERSON NAME) (CITY) apm 7 aoe Sider Amer rma
" ” 7 : RY L1TCLE 17/0 Elm ST EET Speaminre 9504 Bl 5.
TD | oa F per FOLLOW UP CODES
CHDP ASSESSMENT NO CONTRA L NO DX/RX INDICATED OR ROW 4. 0X PENDING/RETURN visit
PROBLEM | INDICAIED | tspropune Come UNDER CARE SCHEDULE
indicate outcome for each SUSPECTED ds; NEW KNOWN 2 qT oA RESULT, RECHECK S. REFERRED ’o ANOTHER EXAMINER
screening procedure : FEES FOR DL/RX
VA . B cE -D 3. DX MADE AND RX STARTED $. BEF REFUSED
TOR RIEL EA | ji | 4 ERRED TO ro NUMBER
uo x30, 9 "keno You Et 5) 8 / 3%
02 DENTAL ASSESSMENT /REFERRAL I > REFERRED 10 TELEPHONE NUMBER
03 NUTRITIONAL ASSESSMENT | i
rH AT a COMMENTS/PROBLEMS
05 DEVELOPMENTAL ASSESSMENT o a8 IF A PROSLEM IS DIAGNOSED THIS VISIT. PLEASE ENTER
06 SNELLEN OR EQUIVALENT ® AL, 20 —— YOUR DIAGROSIS If THIS ARTA
07 AUDIOMETRIC
08 HEMOGLOBIN OR HEMATOCRIT
09 URINE DIPSTICK
10 COMPLETE URINALYSIS
v.22! |), AZ Fine b0 oUTIVNE
3.0]
1% \Dewrhh CREE,
of 5G
T8 MULTIPUN 20 sme 0 2
C00E OTHER TESTS SEE CODES ON REVERSE SIDE OF LAST PAGE OTMER TESTS
The RANT _L fous ih :
LETuenN Two WEEKS
4 5 DH402]08 bid GU 74 di | Fou Leo [ESING
NF
TH
RE
ES
vr
5 4 3 i Sm Dr ys La lllr a. Corn
Bd HEAD START / STATE ResCHODL
GIVEN TODAY | NOT GIVEN TODAY | would effect his/her
NOW UP si NOT | ALREADY | REFUSED opr a Whi ICD 9 CODES
IMMUNIZATIONS oR hi} € OR ATE Ton CONTRA Preschool Program. : 1 | | 2 | 3
AGE AGE AGE INOICATED |
A 8 D | !
31 POLIO - ORAL | Vv, 1] THE QUESTIONS BELOW
32 DPT OU/Td | Vv 2 MUST BE ANSWERED
33 MMAR! MRC EF MRP . 1. Patient 1s Exposed to Passive (Second Yes [] No XK
38 Hib CV vv’ 33 Hand) Tobacco Smoke.
2. Tobacco Used by Patient. Yes] No X
3. Counseled About/Referred For Yes] No
PATIENT VISIT {/) TYPE OF SCREENY/) JQTUAL FEES Tobacco Use Prevention/
psi ve | Rowing Vist [1 Intal | Perm ) Zed & Cessation.
PROVIDER OF SERVICE: fume. bus, Jx7a3 ys) Y 5 / (1) Enrotied in WIC [2] Referred to WIC
Mumba ww, INS? NOTE: WIC requires Ht., Wt. and HGB/HCT
1] PARTIAL SCREEN [7] SCREENING PROCEDURE RECHECK
ACTOMpAYES PRIOR PM Let DATED |
TIENT COUNTY IDENTIFICATION RUNBER
iki fii HET sonny ST b
32 4 ax RA OTHER THAN ABOVE VM coverad by Mads-Cal. enter Medi-Cal 1.D. number above AND atuach PO £. ladet
Thus is to certify thot the screening information is frue and complete. ond the resvits explained fo v ; _ . fo Presa
the child or hrs parent or guordion. | understand that payment ond sotisfoction of this clown moy Fatewt ot <0 ladl-00) 200 WES. 20 Re Cov hii
be from Federcl or Stote funds, ond that ony folie cloims. statements or documents or conceol- VW PE 160 Submitiad ter &
ment of 0 maternal loct, moy be prosecuted under applicable Federal or State low. | olso certify | Tia Personne. PRSRCT Buesie NEAR START Sunt
thot ag of the sexes billed on thy form hove been or will be billed to Med:-Col, the ji
v
STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
Daf
CONFIDENTIAL SCREENIG/BILLING REPORT rvs wat omen crop) oioimes Sh ose oo
PW 160 MSP (4 0)
.33"
HEAD START/STATE PRESCHOOL CHILDREN (See Example 25.)
Children attending Head Start/State Preschool programs have a special PM 160 (PM 160 HSP).
The form, which is to be used only for Head Start/State Preschool children, is sent or brought to
the CHDP provider by the child's parent or Head Start or State Preschool program personnel.
The name of the child and the State Preschool Project number or the Head Start Grantee
number will have been entered in the box by the Head Start or State Preschool program. If this
information has not been entered, contact the local CHDP program. Claims without a number
will not be reimbursed.
The PM 160 HSP has 5 copies.
Copy 1 (white) is to be sent for claim payment.
Copy 2 (yellow) is to be sent to the local CHDP program.
Copy 3 (white) is to be kept in provider's file.
Copy 4 (goldenrod) , must be given to parent; parent may take copy 4 to Head Start
Copy 5 (pink) } or State Preschool program.
SPECIAL INSTRUCTIONS:
ENTER HEIGHT, WEIGHT, BLOOD PRESSURE, HEMOGLOBIN/HEMATOCRIT VALUES. These are
REQUIRED BY HEAD START/STATE PRESCHOOL PROGRAMS. (Follow the instructions on
pages 13—16.)
Enter any health information which would affect the child's participation in the Head
Start/State Preschool Program in the “COMMENTS/PROBLEMS" area.
CHECK BOX NO. 1 if the Head Start/State Preschool child is covered by Medi-Cal. Follow
instructions under PATIENT ELIGIBILITY, MEDI-CAL, on page 30. Be sure to attach POE label, if
available.
CHECK BOX NO. 2 If the Head Start/State Preschool child is NOT covered by Medi-Cal and is
not enrolled in a Prepaid Health Plan.
CHECK BOX NO. 3 (INFORMATION ONLY) if payment of a health assessment for a Head
Start/State Preschool child is covered by a source other than CHDP reimbursement.
The CHDP Eligibility Information (DHS 4073) form is not required.
IF SCREENING SERVICES WERE PROVIDED AT A LOCATION OTHER THAN THE PROVIDER'S ADDRESS
AS GIVEN ON THE PM 160, THE SITE WHERE SERVICES WERE PROVIDED MUST BE IDENTIFIED IN THE
“PROVIDER OF SERVICE" BOX.
CLAIMING FOR OTHER THAN A COMPLETE HEALTH ASSESSMENT:
A PARTIAL SCREEN IS DONE FOR THE FOLLOWING REASONS:
Procedure(s) performed that could not be provided during a previous CHDP Health
Assessment; and/or
Needed immunizations given when another complete CHDP Health Assessment is not yet
due; and/or
Procedures required by the WIC or Head Start programs on children participating in their
programs who have had a complete CHDP Health Assessment but are not yet due for
another complete health assessment.
A SCREENING PROCEDURE RECHECK
A Screening Procedure Recheck is done because, during a prior CHDP Health Assessment,
the accuracy of the result of the procedure was in doubt and a Follow-Up Code 2 was
entered in Column C or D on that prior PM 160 for the Screening Procedure to be
rechecked.
PARTIAL SCREEN INSTRUCTIONS: (See Example 28.)
}. Complete the patient and provider identifying information;
2. Enter a check mark (V) or a Follow-Up Code in an Outcome Column for the procedure
given:
3. If immunizations are given, complete the entire Immunization Section (see directions on
pages 17 through 20);
4. Enter the DATE OF SERVICE;
5. Enter a check mark (V) in the box labeled PARTIAL SCREEN;
6. Enter the date of the Complete CHDP Health Assessment from the prior PM 160 in the box
labeled ACCOMPANIES PRIOR PM 160 DATED;
7. Complete the PATIENT ELIGIBILITY information;
8. Enter FEE(S); and
9. Enter TOTAL FEES.
NOTE: A History and Physical Examination is not considered a "Partial Screen” or a "Recheck."
A prior PM 160 which includes a History and Physical Examination must be on file for
patients for whom the provider gives and bills a "Partial Screen.”
When procedures are given to meet Head Start or WIC requirements, for children who
have had a complete CHDP Health Assessment but are not yet due for another
complete health assessment, the notation "Required by WIC" or "Required by Head
Start" should be entered in the "Comments/Problems" area.
2a
SCREENING PROCEDURE RECHECK INSTRUCTIONS: (The next two pages [Examples 26 and 27] are
examples of the first and second PM 160s submitted when performing a Screening Procedure
Recheck.)
}.
2.
7
8.
Complete patient and provider identifying information;
Enter a check mark (v) in the box labeled SCREENING PROCEDURE RECHECK;
Enter a check mark (v) or a Follow-Up Code in an Outcome Column for the assessment
procedure(s) being done;
Enter the DATE OF SERVICE;
Enter the DATE OF SERVICE from the prior PM 160 in the box labeled ACCOMPANIES PRIOR
PM 160 DATED;
Complete PATIENT ELIGIBILITY information;
Enter FEE(S); and
Enter TOTAL FEES.
NOTE: Only Screening Procedures 06 through 20 may be submitted for payment as rechecks.
«36 -
v
LJ LJ
’
EXAMPLE 26
CLAIM CONTROL NUMBER
_FOR STATE USE ONLY
- STAPLE
20 %0F STAPLE HERE
N BAR AREA |
L
: ' Boe NAME Bos A (FIRST (INITIAL) 7 MEDICAL RECORD NO 5 Cade
% \ Husa N ELEPHONE HUMBER NEXT VISIT a £1 3IR AGE, |SEX cre {PATIENTS COUNTY OF RESIDENCE L Shei
fod o Oav ! < ur Fir £1 3 Ans, \ Serpents Tl 212.0%) 72. te
RIAL SIBLE PERSON NAME) ho {Cry /¢/ Shirk is
- 7 Ore Lr0y NOE 198 WN Erm SHEET OSnersminto 958/ Iz re
REFUSED | PROGuEM SUSPECTED LATE OF SERVICE FOLLOW UP —_
CHDP ASSESSMENT SONIA. Gi diy JY 90 L ¥0 DURE INDICATED OR NOW 4. 0X PENDING/RETURN VISIT
an «NOICATED. i roonate Column UNDER CARE SCHEDULED
Indicate outcome for each | SUSPECTED | es NEW | KNOWN | pr auesTIawAsLE RESULT. RECHECK & REFERRED 10 ANOTHER EXAMINER
screening procedure | | FEES SCHEDUL FOR DX/
vA 8 0 | 3 ox MADE Ed RX STARTED §. Yili REFUSED
01 HISTORY ana PHYSICAL EXAM
—
J
l
o
T= REFERRED 70 TELEPHONE vUi4BES
02 DENTAL ASSESSMENT/REFERRAL
03 NUTRITIONAL ASSESSMENT
04 ANTICIPATORY hgance |
~E AL TW EDUCAT |
05 EE yp ASSESSMENT
|
REFERRED TO TELEPHONE MLBE?
$3 | |
|
COMMENTS/PROBLEMS
06 SNELLEN OR EQUIVALENT | 06 oy oo ] YOUR QI1ACNOSIS IN THIS AREA
07 AUDIOMETRIC
v.,
Vv.
x.
ih '
YY ER 0
IF A PROBLEM 1S DIAGNOSED THIS VISIT PLEASE INTER
18 HEMOGLOBIN OR HEMATGCRIT | RR RA CF LO sul? Xu ES TIOWA BLE
09 URINE DIPSTICK
10 COMPLETE URINALYSIS 7eTuen In
11 TB MULTIPUNCTURE ' in
|: g3H
12 TB MANTOUX ii 7.53 Two (2) Weeks
v_
Y
TT
00€ OTHER TESTS | SEE CODE REVERSE SIDE OF LAST PAGE | CODE|{ OmdeR TESTS | ~ ;
| ur Fox K€ CHECK
[ i | | :
| | |
A M HEIGHT WEIGHT “90 URE | |
x 0 0433104100]! EL
=GB HCT BIRTH WEIGHT |
| GIVEN TODAY “I0T GIVEN TODAY ! :
EET AEE C2 § LODES
IMMUNIZATIONS LTR OE SR. TH : 3d 2 :
Posse vk GE | NOICATED | 4
a 1 9 Cy lite
31 POLIO - ORAL vi 3 THE QUESTIONS BELOW
32 0PT Dulg | inf Y | 12 = MUST BE ANSWERED
1 or ™ | R 13 SH #, 33 ii Murl Rl v/ | 33 . 1. Patient 1s Exposed to Passive (Second Yes| Ne
28 Hip CV i Vv | | 38 | Hand) Tobacco Smoke. fis
: :
| | 2. Tobacco Used by Patient Yes is 4
I oY
| | . 3. Counsetea About/Referrea For Yes, No
PATIENT VISIT | TYPE OF SCREEN TOTAL FEES | Tobacco Use Prevention/ nd
| sem ret a Rowe vist [ion | A] porase tg [,’] Ar | Cessation.
PROVIDER OF SERVICE: Name, Address. PROVIDER NUMBER wr | {1] Enrolled in WIC (2] Referrea to WIC
Number (Please Include Area Code) X X X [X 2 i Af A | NOTE WIC requires Ht.. Wt. and HG8/HCT
[1 PARTIAL SCREEN SCREENING PROCEDURE RECHECK
|
ACCOMPANIES PRIOR PM 160 DATED | | !
Th 5 Ta 70
os Sir
35eed B 95714
SITE OF SERVICE IF ne MT: ATIVE
This 15 10 carnfy that the screening information 11 true and complete. and the results expiained to
the chiid or his parent or guardian. | understand that payment ond satisfaction of this cioim may
be Irom Federal or State funds. and that any foise claims, statements or documents or conceoi
ment of a materiol fact, moy be prosecutec under applicaole Federal or Stote iow. | also certify)
the services biilgd on this form hove been or wil oe billed 10 Meai-Cal, the!
iin 5 34) 154551962.5¢ | ELIGIBILITY
if covered by Medi-Cal. enter Medi-Cal 1.0. number sdove AND attach PO € abet a
shaded area dDeiow
Vv Patient not on Medr-Cal Parent or guardian kas read and signed ehibinily statement.
Sighatyee oF Seovinre . SaTE Y
¢ONFIDENTIAL SOREENING/BILLING REPORT
a7
STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
Play Meai-Cai; CHOP
COPY 1 - MAIL TO MEDI-CAL CHOP
PO Box (5300
Sacramento. CA 35351-1200
EXAMPLE 27
~LAIM CONTROL NUMBER FOR STATE 1JSE ONLY
STAPLE
20 OT STAPLS ' HERE
IN BAR AREA
{OL NAME i (FIRST UNITIAL) 7 MEDICAL ST NO UA. Code | |
2 AN
E, omen PATI S COUNTY OF RESIDENCE CO0E EQEPH 0 7¢ 1 egy VISIT 3 eran nan
03103125] % Ba AERANENTD 34 3 GATT JL... i=
SIBLE PERSON J _( (CITY) 2, 4G 3 Me Amer ‘gan
} | Nhe
LHmy Nok 1184 Ewm STREET \ JACK qgmeNT 45 &7 7 I
REFUSED PROBLEM SUSLLRD OF SERV! FOLLOW UP CODES
CHDP ASSESSMENT | CONIA: 034 /) L NO DX/RX INDICATED OR NOW 4. OX PENDING/RETURN VISIT
Ral “NDICATED. UNDER CARE SCHEDULED
Indicate outcome for each SUSPECTED | 1 1 QUESTIONABLE RESULT. RECHECK S REFERRED 10 ANOTHER EXAMINEF
screening procedure NEEDED FEES SCHEDULED FOR DX/RX
v A 8B 3. DX MADE AND RX STARTED 6. REFERRAL REFUSED
01 HISTORY ana PHYSICAL EXAM | |
REFERRED TO
| TELEPHONE vytABES
02 DENTAL ASSESSMENT /REFERRAL | |
03 NUTRITIONAL ASSESSMENT | |
04 ANTICIPATORY GUIDANCE |
~EALTH EDUCATION
CS DEVELOPMENTAL ASSESSMENT]
| REFERRED TO
-
| TELEPHONE “IUMBER
COMMENTS/PROBLEMS
06 SNELLEN OR EQUIVALENT | e)o, | 06
If 4 PROBLEM 1S DTAGNOSED THIS VISIT PLEASE ENTER
YOUR DIAGNOSIS IN THIS AREA
07 AUDIOMETRIC
|
| lor {
08 HEMOGLOBIN OR HEMATOCRIT | i i i 08 |
J9 URINE DIPSTICK | | | 09 |
10 COMPLETE URINALYSIS | 10
11 TB MULTIPUNCTURE | Ii |
12 TB MANTOUX | [ | | 12 |
Co0E | OTHER TESTS | SEE CODES ON REVERSE SIDE OF LAST PAGE | COOE| OTHER TESTS
| | i
| | |
| |
A M HEIGHT WEIGHT BLOOD PRESSURE
HGE CT BIRTH WEIGHT
| GIVEN TODAY NOT GIVEN TODAY -
CT at | ae | TErusES ; ICO 9 CODES :
IMMUNIZATIONS JOR JAEFOR | OAIEFOR | CONTRA. : ! 2 | :
vO Ge NOICATED |
ALB C p) Fo i
31 POLIO - ORAL | 3 THE QUESTIONS BELOW
32 DPT Dt/Td | | 2 L MUST BE ANSWERED
IIMMRITL MUR? MRC? | B L. Patient 1s Exposed to Passive (Second Yest = No
38 Hib CV i Hand) Tobacco Smoke. Th ug
| | 2. Tobacco Used by Patient Yes{. Noi
| = ~
| | ! 3. Counseted About/Referred For Yes. 1 No. PATIENT VISIT (yv) TYPE OF SCREEN (vy) JOTAL FEES Tobacco Use Prevention/
a [7 toveme via [7 in HT Frese £LO0UV Cessation.
PROVIDER OF SERVICE: Name. Address.
{eseohone Number (Please inciuoe Ares Codel
PROVIOER NUMBER
219
SITE 02e IF NENT THAN 21.5
(1] Enrotied in WIC (2] Referrea to WIC
NOTE: WIC requires Ht., Wt. and HGB/HCT
PARTIAL SCREEN
ACCOMPANIES PRIOR PM 160 DATED
SCREENING 0310 01140
10.3 |
This 1s to cernfy that the screening information 1s true ond complete. ond the resuils eapioned to
the child or lus parent or guardian. | undersiond that payment ond satisfaction of thi claim may
be from Federol or State funds. and thot ony folse claims. statements or documents or conceai-
ment of a mareriol foct, moy be prosecuted under applicoble Federal or State low. also cernty
[ one of th rvices billed on ths lorm have oeen or wiil i 73 y Me
fo or gi Ei providers
PATIENT
ELIGIBILITY 3 84 CED |
if covered Dy MerCal, enter Medr-Cal 1.0. sumber above AND attach P 0 €. ade
shaded wes deiow
v
/
Vv Patient not on MedeLal Parent or guardian Rag read and Signed ehgidiuly statement.
are 54) the
SICRAJURE OF canvines DATE
CONFIDENTIAL pet 1 of
38 -
STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTION PROGR;
CCPY 1 - MAIL TO MED! CAL CHOP vi
Med:-Cal/CHDP
PQ. Box 15300
Sacramento. CA 35851 1200
2 ’
& 1
’
EXAMPLE 28
CLAIM CONTROL "NUMBER . FUR STATE Usk cites
Tha oy | ad STAPLE
100 NOT STAPLE gum
[1m BAR ARCA fr
HERE
ETE |
: Eivt NAME (LAST) eel) NTA) MEDICAL RECORD NO i
t L.A. Code Tire. Lowey oT GE 23 85678
s BIRTHDATE $8 von K S COUNTY OF RESIDENCE CODE FE NUMBER NEAT VISIT TAmencan tngwan
t oy
3 Blac 21101 89| 2 [M@ Spcesminto 13915853232. 1031 192): EE
: RE SIBLE PERSON (NAME) "eg S$ (CITY) wp 7 v SNE Amer IH span
7, 700 /7)ARY Little [Oe Fim O1eEET ShexsmenTo 4534 6) 5
160 RR I El FOLLOW UP CODES
CH DP ASSESSMENT | >» . 1/731 JO] 1 vo ow moicate on now 4. DX PENDING/RETURN VISIT
PROBLEM HOCAIED A ate Column UNDER CARE SCHEDULED
Indicate outcome for each susricten | 0 | NEW | KNOWN 2. QUESTIONABLE RESULT, RECKECK 5. REFERRED TO ANOTHER EXAMINER
screening procedure FEES EDULED FOR DI/RX
vA vB c 0 3, DX MADE AND RX STARTED 6. REFERRAL REFUSED
REFERRED TO TELEPHONE NUMBER
01 HISTORY and PHYSICAL EXAM
01
02 DENTAL ASSESSMENT /REFERRAL REFERRED TO TELEPHONE NUMBER
03 NUTRITIONAL ASSESSMENT |
04 BATH ERATION COMMENTS/PROBLEMS
05 DEVELOPMENTAL ASSESSMENT IF A PROSLEM IS DIAGROSED THIS VISIT. PLEASE ENTER
06 SNELLEN OR EQUIVALENT 06 —— TOUR DIAGROSIS IR TKIS AREA
07 AUDIOMETRIC 0
08 HEMOGLOBIN OR HEMATOCRIT 08
09 URINE DIPSTICK ®
10 COMPLETE URINALYSIS 10
11 T8 MULTIPUNCTURE In
12 TB MANTOUX 12
coof | OMMERTESS | SEE CODES ON REVERSE SIDE OF LAST PAGE OTHER TESTS J
> L000 LERO| VV A dod $5
A M HEIGHT WEIGHT BLOOD PRESSURE HEAD STARY/ rid oa
. fi, 5 ig
£3 1) STEPRESCHOOL | / 7; F [ains L0REUER
HGB HC BIRTH WEIGHT Please enter valves| T= S&T
0 fhe 1a and provide
any formation about
's health which ART / STATE PRESCHOOL
GIVEN TODAY | NOT GIVEN TODAY | me cd fineaith wich HEAD ST
Nowe J SALMO 1 MRC i REVO PE I Wd ICD 9 CODES
IMMUNIZATIONS %on ATE FOR | OATE FOR | CONTRA | Preschool Program ] 1 | | 2 | | 3 | AGE AGE AGE INOYCATED
A 8 Cc D |
31 POLIO ORAL an THE QUESTIONS BELOW
32 DPT DUTG I" MUST BE ANSWERED
B3MMR(} MuR(F MRP n 1. Patient is Exposed to Passive (Second ~~ Yes] No[]
38 Hib CV 38 Hand) Tobacco Smoke.
2. Tobacco Used by Patient. Yes] No]
3. Counseled About/Referred For Yes[] No[]]
PATIENT VISIT (V) TYPE OF SCREEN"(Y) TOTAL FEES,» Tobacco Use Prevention/
Bt (ew [ow [lowe [22.@F7] Coen
Pion t ¥ hve: iy vor 0572 3 JZ 4 5 (1] Enrolled in WiC [2] Referred to WiC
NOTE: WIC requires Ht, Wt. and HGB/HCT
NM BPEL 1130 LL fu SCREEN [7] SCREENING ALTE)
PANIES PRIOR PM 160 DATED 0310
[Max NM PATIENT COUNTY AID IDENTIFICATION RUBBER
Shee A MENTO Tike gsviy [ER CT |
SERVICE IF OTHER THAN ABOVE: VM covered by Medi-Cal. enter Medi-Cal 1.D. amber sbove ARD attach PO €. label
haded ares Delom.
This is to certify that the screening information is true ond complete, ond the results explained to 3
the child or hes porent or guardian. | understand thot poyment ond satisfaction of this cloem may VP Aot;o8 Bd-Dul 204 23 00 gRbag for ze sevice
be from Federal or State funds, ond thot any false claims. statements or documents or conceol- VN PH 160 Submitted fer tatermaticn Only
meni of o nen) foct, moy be prosecuted under opplicoble Federal or State low. | olso certify | 3ialt resscnooL FEOKCT Bumete STAR! CRARTEL
Cl services billed on phi form hove been or will be billed to Med:-Col, the 00¢
pole 17, /
or = surance provide
an R80 JI JJ3 /5D STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
DATE
CONFIDENTIAL SCREENING/BILLING REPORT oer) wut romeoicn cor —) _ Soomrons ssi 100
PM 160 HSP (4790)
. 30.
ATTACHMENTS
ml) EN
Medi-Cal Recipient ID Card (MC 300, Green)
(Issued by State)
REYRO: NOV 88 UZsL5/1981 & LASFNAME FIRSS
SSA® S45894F15 2.543B96T156F 27
Hy _21188MBLN
:LASTNAME FIRSS
§5=2T=d01TIS3~1=01 2e6Qa . 545896T156F 27,
County Identification Number
FIRSTNAHE © LASYMARE “7 21188MBLN
| Ly] ' . LASTNAME FIRSS
BOX ARG: FA 27 7 545896T1S&F 27,
TWAIN HARYEs CA ¢, 95383 211B8PBIN
fi a he, ~ LASTNAME FIRSS
Sorins Sdcurity Nomber __HEDSID 349896715 545896T156F 27,
SE SN R012 21188P81N
(© .. LASTNAME FIRSS
SOC: 0000 Q/fC:=H 545896T156F 27,
L322 21183P81N
RECIPIENT NAME CHECK i131
X SEX
SSN Teun
AME\F [R)S5—_— AID CODE
545896 TISEF> 31
MEDICARE __—" 21183P31N RESTRICTED SERVICES
\ —
NDIGATOR nt N ~~ HEALTH CARE PLAN CODE
VALID MONTH OTHER COVERAGE CODE
YEAR
SEBVICE LEVEL SIRTH YEAH
-42-
Temporary Medi-Cal ID Card (MC 302)
(Issued by County)
MEDI-CAL IDENTIFICATION CARD mo sot
PLEASE SIGN AND DATE THE BACK OF THIS CARD ~
LASTNAME FIRSTNAME VALID NOV 1948
| Sauny, RECIPIENT-ID 7788-80216 DOE 02 02-905
Isenimicstion~("" coUNTY 1D J34-30-7780215-1-02 SEX M
DICARE 1D 778880216 OTHER COVERAGE XN
Social Security
Number
DISTRICT 9722
CASEWORKER 9227
Chat Aarnsasntlatanra
satettsddsAnntos
nrasrans
& &
ah
«a PRIOR AUTHORIZATION FOR Ga
«a NON- EMERG VISITS AND DRUGS ec
ET TE FEEL EEE EEE ERY ¥ FH fs ne L- e a
2NO48R306142517 105F-312 31-24)
RECIPIENT NAME CHECK DIGIT COUNTY CODE
MEDICARE STATUS A NTL GO
55 i ed IR
N— _7788802163* 34 302 YEAR OF BIRTH
1188+ POE oe
RETRO DV Th
ce OTHER bo CARE LTC DOLLAR AMOUNT
COVERAGE SERVICES PLAN CODE OR SOC CERTIFICATION DATE
-A3
State of Catormig - Health ana Welfare Agency
of oath ang Disability Prevention Program
Alameda County
Alpine County
Amador County
Butte County
Calaveras County
Colusa County
Contra Costa County
Del Norte County
El Dorado County
Fresno County
Glenn County
Humboldt County
Imperial County
Inyo County
Kern County
Kings County
Lake County
Lassen County
Los Angeles County
Madera County
Marin County
Mariposa County
Mendocino County
Merced County
Modoc County
Mono County
Monterey County
Napa County
Nevada County
Orange County
RESIDENCE CODE LIST
Placer County
Plumas County
Riverside County
Sacramento County
San Benito County
San Bernardino County
San Diego County
San Francisco County
San Joaquin County
San Luis Obispo County
San Mateo County
Santa Barbara County
Santa Clara County
Santa Cruz County
Shasta County
Sierra County
Siskiyou County
Solano County
Sonoma County
Stanislaus County
Sutter County
Tehema County
Trinity County
Tulare County
Tuolumne County
Ventura County
Yolo County
Yuba County
City of Berkeley
Summary of Pediatric Immunization Recommendations
Immunization Unit, Effective May 1990
California State Department of Health Services
Children Beginning Immunization In Early Infancy
Age Vaccines
2 TOTS (6==10 WOBKSEY iru.icrsivhursibnnnsorissrvanssrasisruminsen DTP & OPV (polio)'
ATION . oo. hi ivivseraniiversssasndrasiotanatatan sank esrsveriitatnantansy DTP & OPV (polio)
Fu rt 1 DU re CN CE ed ARR TR DTP
I TE Er Re REN, MMR, DTP & OPV and Hib-conjugate’
4—6 years (before Choo! entry) ............cccoerrierinne. DIP. OPV, & MMR’
14—16 years (and every 10 years thereafter) ........... Td
1. Can start at this age even for premature and/or low birthweight infants who are
otherwise well.
2 Give MMR, DTP, OPV, and Hib simultaneously. at separate sites.
3. See NoteF
NOTES
A. If delay occurs between doses, regardless of the length, the series does not have
to be restarted. Pick up the schedule where it left off.
B. TB skin testing is not a prerequisite to measles vaccine. If needed. a TB skin test can
be given before or on the same day as measles (or MMR) vaccine.
C. Different live vaccines (e.g.. MMR, OPV) not given on the same day should be
given no less than four weeks apart. Successive doses of OPV should be given no
less than six weeks apart.
D. Optional measles immunization schedule recommended by the USPHS for some
epidemic or hyperendemic counties only: MMR at age 12 months (on or after the
first birthday). No repeat MMR at 15 months needed if first dose given at =z 12 mos
E. Regarding the California School immunization Law, a child entering a sChool or a
child care center may be exempted from immunization requirements because of
(a) a permanent or temporary medical reason (an explanatory letter from the
physician stating reason and time period of exemption is required) or (b) because
of a parent/guardian’s personal or religious beliefs.
F. For clinics using Immunization Unit-supplied vaccine, a second dose of MMR
vaccine may be given only if the Immunization Unit states that sufficient vaccine is
available. For children age é and older already in school who have had only one
MMR dose, take advantage of any office visit to give a second dose of MMR.
College entrants born in 1957 or iater with only one dose should be given a second
dose of MMR. The second MMR dose should be at least four weeks after the first
dose. For preschool-age chidren who received their tiist MMR vaccine dose at
age 12—15 months or olde, the second MMR dose Is not normally needed until
kindergarten entry age.
Children Beginning Immunization
After Early Infancy’ but Before Age 7 Years
Date/Age Vaccines
TT de ROR DIP OPV. & if = 15 mo. old MMR and Hib-conjugate’
6B weeks olor ISL DIP BL OPV .....oiir tie sicnvosiansicasg oe derugnidos DTP & OPV
4—B weeks oer 2nd DIP & OPV ...........c. cists siyiis sin veossrasensnes DIP
6—=12 months Ole DIP... ce vaha sirens prpunmsansss iinevene DIP & OPV
4—6 years (before sSChool entry) os DIP & opPVv? & MMR?
14—16 years (and every 10 years thereafter).......................... Td
1 if started in first year of life, give first three DTP doses and first two OPV
doses as per this schedule and give MMR and Hib at 15 months.
2. Hib may be given simultaneously, at separate sites, with MMR, OPV,
and/or DTP. Immunologically normal children age 5 years and older
do not need Hib vaccine.
3. The USPHS and the AAP consider these doses necessary unless the
fourth DTP dose and the third OPV dose were given after the 4th
birthday. California's school entry law, which is a minimally
acceptable standard rather than an optimum recommendation,
does not require these doses unless the fourth DTP and third OPV
doses, respectively, were given before the second birthday.
Physicians and clinics should follow the USPHS/AAP recommendation.
4 See Note F.
Children Beginning Immunization
At Ages 7—17 Years
Date vaccines
ESE VBI. ois Foi Vinah sw nnvasisnuianss snus van sndmenss Touihn ve samBhniies sts 1d, OPV, & MMR
bn 8 WREKS OHEE YSE TOE OPV ..c.icvnnrisivivis os rinstigivins cute: Td, OPV & MMR!
6—12 months aller 2nd 1a & OPV ......c.cuiinniiains 1d & OPV
Every 10 years thereafter... Jo
| See Note F.
« ‘State of California-Health and Welfare Agency Department of Health Services
Child Health and Disability Prevention
CHDP ELIGIBILITY INFORMATION
DO NOT GIVE TO MEDI-CAL PATIENTS.
A separate form must be completed for each patient for each visit.
Patient's Name Birthdate
Address Age
(years) (months)
Infants, children, and youth may be eligible for a state-paid health examination. The information you give below
will determine if a health examination can be given at no charge to you. This information is only needed if you
want to apply for a state-paid CHDP health examination. The information you give is confidential. THIS IS A
VOLUNTARY PROGRAM.
YES NO
1. Is your child less than 19 years of age? [1 J
2. Are you an emancipated minor less than 19 years of age? OJ 0
IF YOUR ANSWER TO EITHER OF THE ABOVE QUESTIONS
IS YES, PLEASE ANSWER THE QUESTIONS BELOW.
3. Is the patient named above:
i []
a. On Medi-Cal now? *
J []
b. Ina Prepaid Health Plan (for example, Kaiser-Permanente)?
4. How many people are in your family?
5. How much money does your family make before taxes? Monthly or Yearly
NOTE: IF YOUR CHILD IS LESS THAN THIRTEEN (13) MONTHS OF AGE AND BORN IN THE UNITED
STATES, YOU SHOULD APPLY TO YOUR LOCAL WELFARE DEPARTMENT FOR MEDI-CAL CARD TO PAY
FOR ALL OF YOUR CHILD'S HEALTH CARE INCLUDING SICK CARE.
| certify under penalty of law that the above information is correct.
Signature of Parent/Guardian or Emancipated Minor Date
Relationship to Patient
An individual has a right to review records containing his/her personal information. The official responsible for
keeping this information is the Chief of the CHDP Branch, Department of Health Services, 714 P Street, Room
708, Sacramento, California 95814, (916) 322-4780 (Title 17, CCR Sections 6802 and 6832). A copy of this
information will also be kept with your child's medical record.
Patients eligible only for pregnancy and/or emergency services with their Medi-Cal card should check the "NO" box for Medi-Cal
eligibility.
NIQ 4A77 RilinAnal 12/00 - 48 -
Child Health and Disability Prevénton
4
INFORMACION CON RESPECTO A SU ELEGIBILIDAD PARA EL PROGRAMA DE SALUD
Y PREVENCION DE INCAPACIDAD PARA NINOS Y ADOLESCENTES (CHDP)
DO NOT GIVE TO MEDI-CAL PATIENTS.
Debe completar una forma por separado para cada paciente en cada visita.
Nombre del paciente Fecha de nacimiento
Direccion Edad
(anos) (meses)
Es posible que bebés, nifios y adolescentes, puedan ser elegibles a recibir un examen de salud pagado ror el
estado. La informacion que nos proporcione enseguida, determinara si le podran proporcionar un examen de
salud gratuito. Esta informacion solamente es necesaria si usted desea solicitar un examen de salud pagado por
el estado del programa CHDP. La informacién que nos proporcione es confidencial. ESTE ES UN PROGRAMA
VOLUNTARIO.
Si NO
1. ¢Tiene su hijo(a) menos de 19 afios? [] 1
2. Es usted un menor emancipado y tiene menos de 19 anos de edad? #2 LJ
SI SU RESPUESTA A ALGUNA DE LAS ANTERIORES PREGUNTAS ES SI,
POR FAVOR CONTESTE LAS SIGUIENTES PREGUNTAS.
3. El paciente que se nombra arriba:
a. Esta recibiendo Medi-Cal actualmente?* 3 45
b. (Esta bajo cobertura de un plan de salud pagado (p.ej. Kaiser Permanente)? #0 L
4. ;Cuantas personas son en su familia inmediata?
5. ;Cuanto dinero gana su familia antes de impuestos?
mensuaimente 0 anuaimente
NOTA: SI SU HIJO(A) NACIO EN LOS ESTADOS UNIDOS Y TIENE MENOS DE TRECE (13) MESES DE
EDAD, DEBE SOLICITAR UNA TARJETA DE MEDI-CAL A SU DEPARTAMENTO DE BIENESTAR SOCIAL
PARA PAGAR TODOS LOS GASTOS DE CUIDADO DE SALUD PARA SU HIJO(A) INCLUYENDO CUIDADO
DEL BEBE EN CASO DE ENFERMEDAD.
Certifico a sabiendas de que puedo ser sancionado(a) por ley que la informacion proporcionada arriba es
correcta
Firma del padre (madre)iutor 0 menor emancipado Fecha
Parentesco con el paciente
Las personas tienen el derecho de revisar expedientes que contengan informacién personal propia. El oficial
encargado de mantener esta informacion es el jefe de la oficina de CHDP, California Department of Health
Services, 714 P Street, Room 708, Sacramento, California 95814, (916) 322-4780 (Titulo 17, secciones 6802 y
6832 del Codigo de Ordenamientos de California (CCR). También se conservara una copia de esta informacion
en el expediente médico de su hijo(a).
Los pacientes que sean elegibles solamente para servicios de embarazo y/o de emergencia con su tarjeta de Medi-Cal, deben marcar la
casilla "NO" para fines de elegibilidad para Medi-Cal.
40:
204] 4AN713 Rilinanal (3/0) 1]n)
State of Calitornia-Health and Welfare Agency Department of Health Services
HEALTH ASSESSMENT PROCEDURES REQUIRED FOR VARIOUS AGE GROUPS’
Child Health and Disability Prevention Program
Revised May 19907
AGE OF PERSON BEING SCREENED
Under | 1—2 3—4 5—6 7—9 10—12 13—15 | 16—23 2 3 4-5 6—8 9—12 13—16 |17—20
SCREENING PROCEDURE 1 Mo. Mos Mos Mos Mos. Mos. Mos. Mos. Yrs. Yrs. Yrs Yrs. Yrs. Yrs. Yrs.
interval Un 1 Mo. 2 Mos. | 2Mos. | 2Mos. | 3 Mos. | 3 Mos. 3 Mos. | 6 Mos. 1Yr. 1Yr 2 Yrs 3 Yrs. 4 Yrs. 4 Yrs. None
Next Exam
HISTORY AND PHYSICAL EXAMINATION X X X X X X X X X X X X X X X
Dental Assessment
Nutritional Assessment
Developmental History and Assessment
Health Education
PELVIC EXAM®
X %
VISION SCREENING
1
Snellen or Equivalent Visual Acuity Test ; x X X X X X
Clinical Observation X X X eo X X X X X X X X X X Xa
HEARING SCREENING
Audiometric
x X X X X X
Nonaudiometric
X X X X X X X X X
TUBERCULIN TEST?
X X X X
LABORATORY TESTS
ed]
Hematocrit or Hemoglobin
X X : X X X X X X
Urine Dipstick or Urinalysis
X X X X X
VDRL, RPR, OR ART
X X X
Gonorrhea Culture’
X X X
Papanicolau (Pap) Smear
o X X y
Chlamydia Test*
X X
Phenylketonuria (PKU) X
Sickle Cell
May be done once if both anemic and trom specific target groups (see guidelines). he Bun
Free Erythrocyte Protoporphyrin (FEP)
May be done If health history warrants.
Blood Lead Level
May be done If health history warrants.
IMMUNIZATIONS—administer as X X X X X X X X X X X X X X
necessary to make status current.’
PERSONS COMING UNDER CARE WHO HAVE NOT RECEIVED ALL THE RECOMMENDED PROCEDURES FOR AN EARLIER AGE SHOULD BE BROUGHT UP-TO-DATE AS APPROPRIATE.
NOTE:
1 Required unless medically contraindicated or deemed inappropriate by the screening provider or refused by the person.
2 Snellen and audiometric examinations should be done at this age if possible.
3 Recommended more frequently In high risk populations such as recent immigrant and refugee families.
4 Recommended for sexually active adolescents.
5 Summary of Pediatric Immunization Recommendations, California Department of Health Services, Infectious Disease Section, May 1990.
od PS a fond PA rien Cambimne AD YD Ane A017
-51
SCHEDULE OF MAXIMUM ALLOWANCES
Effective August 1, 1985
Issued Mav 1990
A HEALTH SCREENING PROCEDURES: Reimbursement for the procedures listed below shall be ihe amount biied by the provider for the
proceduses performed, up to the maximum allowances specified below
0} History and Physical Examination
New Patient or Routine
Extended Visit Visit
By Comprehensive Care Provider
Adolescent (ages 12—20) §49 &1 $39.60
Late Childhood (ages 5—11) 43 32 33.43
Early Childhood (ages 1—4) 40 84 30.95
infant (birth—11 months) 38 37 28.46
By Health Assessment—Only Provider
Adolescent (ages 12—20) $43.32 $37.13
Late Childhood (ages 5—11) 32.13 30.95
Early Childhood (ages 1—4) 34.65 28.46
Infant (birth—11 months) 218 25.99
21 Pelvic Exam
10.00 (Eff 4/1/90)
06 Snellen Eye Test or equivalent visual acuity test
(Ages 7 years and older) $2.02
(Ages 3—6 years)
4.00
07 Audiometric: Pure Tone Audiometry
Q 21
1 TB: Multiple Puncture Test 4.54
12 18: Mantoux test
7.53
B LABORATORY TESTS: For laboratory tests listed below that the provider performs, reimbursement shai be either the provider's usual!
charge to the general public for the test or the maximum allowance specified below. wnichever is iess. if a iaboratory test is
performed by other than the screening provider, for instance by an outsice lgboratory. the screening provider may bill the
Department's Child Heaith and Disability Prevention Program for the charge made to the provider by the igboratory, plus a charge
not to exceed $4.63 for the provider's collection and handling of the specimen The total shall not exceed the maximum allowance
specified below for the laboratory test
08 Hemoglobin or Hematocrit $3.01
09 Urine "Dipstick”
2.87
10 Urinalysis, routine, complete
4.54
13 Sickle Cell Status (Electrophoresis)
30.11
14 Lead: Free Erythiocyte Protoporphyrin (FEP) 7 50
15 lead: Blood Lead Level 22.45
16 VDRL, RPR or ART
456 (Eft. 1/1/89)
17 G.C. Culture
6.02
18 Pap Smear
¥1.22
19 PKU: Blood
4.54
20 Chlamydia Test
19.25 (Eff. 4/1/90)
C IMMUNIZATIONS: Reimbursement for the immunizations shall be the amount billed by the provider for the immunization, up to the
maximum allowed by the Department. The maximum allowance includes $4 52 for aaministering the immunization and the cost of
the immunizing agent as determined from prevailing market costs by the Departments fiscal intermediary.
Reimbursement may be made for the following immunizations:
31 Polio: TOPV (trivalent oral polio virus vaccine)
First, second, third of series, or booster
32 DPT (diphtheria and tetanus toxoids with pertussis vaccine)
First, second, third of serles, or booster
1d (combined tetanus and diphtheria toxoids, adult type)
Dt (combined tetanus and diphtheria toxoids, pediatric type)
33 MMR (measles, mumps, rubella) vaccine
MuR (mumps, rubella) vaccine
MR (measles, rubella) vaccine
34 Measles vaccine
35 Mumps vaccine
36 Rubella vaccine
37 Hib (Haemophilus influenza Type b) vaccine
38 Hib (Haemophilus Influenza Type b) Conjugate vaccine
39 Polio: IPV (inactivated trivalent poliovirus vaccine).
First, second, third of series, or booster, (Eff. 8/1/89)
If the Immunization agents are supplied at no cost to the provider by the Departments Immunization Assistance Program, the maximum
reimbursement rate shall be $4.52.
Reference: CHDP Regulations (Section 6868, California Code of Regulations).
pe 0
Attachment
Provider Information Notice 85-1
ASIAN AND PACIFIC ISLANDER GROUPS
REPORTED IN THE 1980 CENSUS
ASIAN PACIFIC ISLANDER
Chinese Polynesian
Filipino Hawaiian
Japanese Samoan
Asian Indian Tahitian
Korean Tongan
Vietnamese Other, Polynesian
Bangladeshi Tokelauan
Burmese Polynesian
Cambodian (Kampuchea)
Hmong Micronesian
Indonesian Guamanian
Laotian Other Mariana Islanders
Malayan Saipanese
Okinawan Tinian Islander
Pakistani Mariana Islander
Sri Lankan (Ceylonese)
Thai
Asian not specified’
All other Asians
Bhutanese
Borneo
Celebesian
Cernan
Indochinese
Iwo-Jiman
Javanese
Maldivian
Nepali
Sikkim
Singaporean
Marshallese
Marshall Islander
Eniwetok Islander
Bikini Islander
Kwajalein Islander
Palauan
Other Micronesian
Micronesian
Ponapean
Trukese
Yapese
Carolinian
Tarawa Islander
Melanesian
Fijian
Other Melanesian
Melanesian
Papua New Guinean
Solomon Islander
New Hebrides Islander
Other Pacific Islanders?
1 Includes entries such as Asian American, Asian, and Asiatic.
2 Includes persons who did not provide a specific written cntry but reported "Pacific
Islander.”
Source: Asian and Pacific Islander Population by State: 1980 Supplementary Report No:
PC80-S1-12.
U.S. Department of Commerce Bureau of the Census 12/83.
Child Health and Disability Prevention
PROTOCOL FOR ANTI TOBACCO HEALTH EDUCATION (PATHE)
The Surgeon Generals' reports have documented the harmful effects of the use of tobacco products or exposure
to secondhand tobacco smoke. The positive influence of medical care providers in reducing patients’ use of
tobacco has been clearly established.
In compliance with AB 75, the Child Health and Disability Prevention (CHDP) Program has adopted the
“lowing protocol for use during the CHDP health assessment. CHDP health assessments provide the
~noortunity through education to reduce the exposure to and use of tobacco products by patients. Questions
| :2v<. been added to the PM 160 to reflect providers' implementation of this protocol.
SUGGESTED INTERVENTIONS
(Age and situation appropriate interventions may
include, but are not limited to, the following
examples)
PROTOCOL (Guidelines)
I. Setting (Offices, Clinics, Waiting Rooms) * Adopt a nonsmoking policy for office.
* Advise the patients and staff of your anti-tobacco
A. Promote a tobacco free environment for policy.
patients. Remove ashtrays and tobacco advertisements.
Support nontobacco use behavior.
Use community and professional resources for staff
development related to tobacco use prevention.
Physician and staff offer anti-tobacco advice as a
routine activity during every office visit.
Provide age appropriate anti-tobacco reading
materials for patients in waiting area.
Use varied information approaches, e.g., posters at eye
level for patients, models (e.g., lung), videos, buzzer
board, toys: parent-child interactive activities.
Display "No Smoking" signs.
Use posters / materials with role models that promote
exercise / sports, good nutrition, and prenatal care.
Create opportunities for your patients to ask
for assistance in tobacco avoidance.
II. Health History
A. Include tobacco exposure questions in the * Ask about tobacco use/exposure at every opportunity.
health history and review for family history of | * Incorporate a variety of tobacco questions in the health
tobacco-related conditions. history.
Elicit and record any tobacco use/exposure- Consider:
related symptoms of patient.
How is the patient exposed to lobacco smoke [ use?
Incorporate the response to the following
PM 160 questions into the patient history: What is the patient's /parent's understanding of the
health consequences of tobacco use [ exposure?
1. Patient is exposed to passive
(secondhand) tobacco smoke. Are there role models (parents, siblings, heroes) or
peers influencing the patient in the use of tobacco?
Tobacco used by patient (smoking,
smokeless—chew/snuff). Does the patient who uses tobacco want to stop?
* Consider confidentiality needs of teens and young
adults.
:
PROTOCOL (Guidelines)
SUGGESTED INTERVENTIONS
(Age and situation appropriate interventions may
include, but are not limited to, the following
examples)
111. Physical Examination
A.
A.
B.
D.
As all systems are reviewed, address * Highlight exam of cardiovascular system and lungs
relationships to tobacco use and smoke stressing relationship of smoking to these systems.
exposure:
* Where there is exposure:
1. Oral cavity.
2. Nasal passages. -Relate relevant findings to secondhand tobacco
3. Respiratory system. smoke.
4. Cardiovascular system. : ype ;
ys gan -Discuss irritating effects of tobacco smoke on nasal
5. Skin (color, turgor, aging). a
and oral passages and lung: Decreased number of
: : Stine nasal and sinus fasciculi, increased respiratory
Consider the possibility of tobacco : / : Sy TU ny
he ia Riou teh : SE infections, decreased taste sensttioddy, tnereased
allergies/sensitivities (headaches, rhinitis, : : ip
: rs ou iy stomach cancers, increased cervical cancer, {ung
bronchospasms, sinusitis, bronchitis, otitis
: cancer, and emphysema.
media).
IV. Counscling, Education, and/or Referral
If patient does not use tobacco and is not | * Praise positive health behaviors of patients and
exposed to secondhand smoke: parents.
*Reinforce the positive behaviors. Support patients'/ parents’ choice to avoid tobacco
*Dissuade patients and parents from smoke and use.
beginning to use tobacco. : :
3 ; * Present patients! parents with clear facts related io
, dangers of passive smoke
If patient is exposed to secondhand (passive) i rp
smoke: * Inform patient of the advantages of exercise and good
: : nutrition to assist in tobacco use cessation anda
*Discuss effects of passive smoke. prevention.
*Assist in defining plans to reduce/eliminate
exposure. * Discuss coping skills and avoidance techniques (9
*Chart recommendations and follow up in support continued nonexposure for patients.
future periodic exams.
* Address issues such as role modeling and postiiie
If patient uses tobacco: decision making techniques.
* Advise parents of community resources for anti-tobacco
*Di ffi f : Wr : .
+A Scusse Ss “ges use d / activities (contact local health department or CHDP
ssist in defining plans to reduce/stop Program for listings).
tobacco use.
*Encourage cessation. * Support "wellness" perspective and self-esteem related
*Refer patient to community resources for to nontobacco use.
tobacco cessation support.
*Chart recommendations and follow up in * Advise all tobacco users to stop.
future periodic exams. : .
* Encourage, support, and assist patients wanting to
Answer question # 3 on the PM 160: stop (e.g., set quit date, provide self-help materia:s.
positive reinforcement).
#3. Counseled about/referred for tobacco use ; :
A a g a * Use age appropriate referrals to prevention and
prevention/cessation program. cessation programs
*
-57-
Review progress toward reducing tobacco use ana
exposure at next periodic exam.
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“HEALTH SUPERVISION
ICD-9-CM Codes for Pediatricians
This listing of diagnosis codes is taken from the /nternational Classification of Diseases,
8th Revision, Clinical Modification, and is intended for use in general pediatric practice.
This listing is incomplete, however, and reference to the original text should be made
for less Jrequently encountered conditions. The same pertains to codes for injuries
Child Abuse
Contraceptive Counseling
& Advice
Dietary Counseling
Follow-up Examination,
Unspecified
Hearing Exam
Hearing Problem
Hepatitis Contact
Issue of Medical Certificate
Lab Exam
Mental & Behavior Problems
Normal Pregnancy
Parent-Child Problem
Routine Well Baby
& Child Care
Schoo! Exam
Single Birth, Liveborn,
In Medical Facility
Suture Removal
Twin Birth, Mate Liveborn,
In Medical Facility
Venereal Disease Contact
Vision Exam
Vision Problem
> CRADIOVASCULAR
391
390
746.9
796.2
785.2
401.9
747.0
799.1
392°
754 2
745.1
Acute Rheumatic Fever
w/Heart Involvement
Acute Rheumatic Fever
w/0 Heart involvement
Congenital Heart Disease,
Unspecified
Elevated BP Reading w/o
Diagnosis of Hypertension
Functional Heart Murmur
Hypertension, Essential
Patent Ductus Arteriosus
Respiratory Failure
(Cardiorespiratory Failure)
Rhe matic Chorea
Tetralogy of Fallot
Transposition of Great
Vessels
AAA
GASTROINTESTINAL
783.0
382.01
388.70
389.00
389.2
289.10
380.4
384.01
380.1
381 20
382.00
38101
382.3
381.10
384.20
380.12
Acute Suppurative O.M.
with Rupture
Earache (Otalgia)
Hearing Disorder, Conductive
Hearing Disorder, Mixed
Hearing Disorder.
Sensonreural
Impacted Cerumen
Myringitis, Bullous
Otitis Externa, infective
Otitis Media, (“Glue Ear”)
Chronic Mucoid
Otitis Media, Acute Puruient
Otitis Media, Acute Serous
Otitis Media. Chronic Purulent
Otitis Media. Chronic Serous
Perforated Eardrum,
Non-Traumatic
Swimmer's Ear
This listing was compiled by:
Amblyopia
Anisocoria
Astigmatism
Blepharitis
Cellulitis, Orbital
Cellulitis, Periorbital
Chalazion (Meibomian
Gland Cyst)
Conjunctivitis, Allergic
Conjunctivitis, Bacterial
Dacryocystitis, Acute,
Unspecified
Hordeolum (Stye)
Hyperopia (Farsightedness)
Hyphema
Myopia (Nearsightedness)
Obstructed Nasolacrimal
(Tear) Duct, Neonatal
Pinguecula
Pterygium
Refraction Disorders
Strabismus, Convergent
(Esotropia)
Strabismus, Divergent
(Exotropia)
Conjunctival Sac
Cornea
Ear
Esophagus
Intestine or Colon
Nose
Stomach
Abdominal Pain, infantile
Colic
Anal Fissure
Ankyloglossia (Tongue Tie)
Appendicitis
Calculus (Plaque), Dental
Cleft Lip, Unspecified
Cleft Palate with Cleft Lip,
Unspecified
Cleft Palate, Unspecified
Constipation
Dental Caries
Enamel Hypoplasia
Encopresis, Nonorganic
Encopresis, Organic
Enteritis, Diarrhea
Epistaxis
Flatulence
Gastroesophageal Reflux,
Esophagitis
Geographic Tongue
Gingivitis, Acute
Hematemesis
Hemorrhoids, Anal, Rectal,
Complicated
Hernia, Umbilical
Impacted Teeth
Intussusception
Irritable Colon
Malocclusion, Dental
Melena
Mouth Breathing, Halitosis
Nausea & Vomiting
Pyioric Stenosis, Congenital
rophic
Teething Syndrome
Ulcer, Peptic, Site Unspecified
which require 5digits for specificity.
GENITOURINARY
Enuresis, Nonorganic
Amenorrhea
Atrophy, Testicle
Breast Lump
Cervicitis
Cystitis, Acute
Cystitis, Chronic
Dysfunctional Uterine
Bleeding
Dysmenorrhea
Dysuria
Enuresis, Organic
Gynecomastia
Hematuria, benign
Hernia, Inguinal
Hydrocele
Hydronephrosis
Hypospadias
Mastitis
Mittelschmerz
Pelvic inflammatory Disease
Phimosis, Paraphimosis,
Adhesions of Prepuce
Polyuria, Frequency, Nocturia
Premenstrual Tension
Syndromes
Proteinuria
Torsion, Testicle
Undescended Testicle
Urethral (Meatal) Stricture
Urethritis, Unspecified
Urinary Tract Infection,
Unspecified
Vaginitis & Vulvovaginitis
Varicocele (Scrotal Varices)
Vesicoutereral Reflux
Anemia, G-6-PD Deficiency
Anemia, Iron Deficiency
Hemophilia A (Factor Vill)
Hemophilia B (Factor IX)
Henoch Schoeniein Purpura
Idiopathic Thrombocytopenic
Purpura
Lymphadenitis, Mesenteric
Lymphadenitis, Unspecified
Sickle Cell Anemia
Sickle Cell Trait
Thalassemia
Bacteremia, Unspecified
Candidiasis, Cutaneous
Cat Scratch Fever
Chickenpox
Conjunctivitis, Viral
Cytomegalic Inclusion Disease
Encephalitis, Viral Tick-Borne
Erythema Infectiosum
(Fifth Disease)
Gastroenteritis, Viral
Genital Herpes
Giardiasis
Gingivostomatitis, Herpetic
Hand-Foot-Mouth Disease
(Coxsackie Virus)
Hepatitis A
Hepatitis B
Herpangina (Coxsackie Virus)
Herpes Simplex
Herpes Zoster (Shingles)
HIV Infection (AIDS)
DO NOT ENTER
DECIMALS ON
PM 160
HIV Infection (ARC)
(Excludes AIDS)
HIV Infection
no, require s-digits for spechily)
995.0 Anaphylactic Shock
845.01 Ankie (Dettoid Liganacey
845.00 Ankle, Unspecified Site
910.0 Black Eye, Not Otherwise
Specified
995.5 Child Maltreatment Syndrome
(Child Abuse)
850.9 Concussion, Unspecified
993.3 Decompression Sickness
991.0 Frostbite of Face
991.2 Frostbite of Foot
991.1 Frostbite of Hand
992.5 Heat Exhaustion, U i
992.0 Heat Stroke & Sun Stroke
992.1 Heat Syncope (Collapse)
993.2 High Altitude Sickness
844.0 Lateral Collateral Ligament
of Knee
844.1 Medial Collateral Ligament
of Knee
984.6 Motion Sickness
847.0 Neck Strain (Whiplash Injury)
? Wound,
873.0 Open Scaip Wound
w/o Complication
872.61 Perforated Eardrum, Traumatic
848.1 Temporomandibular Joint
(TMJ) Strain
988.5 Venomous Bile/Sting
QORRECTIONS
Cardiovascular
745.2 Tetrol.
of Fallot
Injuries
"METABOLIC ENDOCRINE
255.2
277.0
250
240.9
755.3
242.0
2429
279.09
244 8
244.9
278 0
Congenital Adrenal
Hyperplasia
Cystic Fibrosis
Diabetes Mellitus
Goiter, Unspecified
Hyperthyroidism. Neonatal,
Transient
Hyparthyroidism, w/Goiter
Hyperthyroidism, w/o Goiter
Hypogammagiobulinemia of
Infancy, Transient
Hypothyroidism, Secondary
Hypothyroidism, Primary
Obesity
MUSCULOSKELETAL
719.4 Arthraigia (Joint Pain)
714 30 Arthritis, Juvenile Rheumatoid
7325 Calkaneal Apophysitis
(Severs Diseass)
754 30 Congenital Dislocated Hip
7320 Epwhysitis, Vertebra!
(Schausrmann's)
727.43 Ganglion of Tandon Sheath
7242 Lumbagn (Low Back Pain)
754.53 Matatarsus Varus
729.1 Myasigia (Muscle Pain)
732.4 Osgood-Schiatter Disease
7654.82 Pectus Carinatum
754 81 Pectus Excavatum
734 Pes Planus (Flat Foot)
754.61 Pes Planus, Congennta!
755.00 Polydactyly, Unspecified Digits
724.3 Sciatica
737.30 Scoliosis, Idiopathic
728.85 Spasm of Muscle
755.10 Syndactyly, Multiple,
Unspecified Sites
726.90 Tendonitis, Unspecified
755.63 Torsion Femur
755.6 Torsion. Tibia
NERVOUS SYSTEM
3J0¢ Adjustment Reaction
30.0 Alcohol Abuse/Drunkenness,
Nondepeandent
307 1 Anorexia Nervosa
314.0 Attention Deficit Disorder
314.01 Attention Deficit Disorder
w/ Hyparactivity
314.00 Attention Delicit Disorder
w’'o Hyperactivity
351.0 Bell's Palsy
307.51 Bulimia
305.2 Cannabis Abuse
343 Cerebral Palsy, infantile
312 Conduct Disturbance
780.3 Convulsions, idiopathic
or Febrile
3154 Coordination Disorder
300.4 Depression, Naurotic
315.31 Developmental Language
Disorder
323 Encephalitis
307.7 Encopresis, Nonorganic
307.6 Enuresis, Nonorganic
ICD-9-CM Codes for Pediatricians
273.)
762.1
776.6
767.6
763.0
763.4
770.8
758.0
767.5
779.3
772.0
768.2
768.3
763.2
767.2
7272.Y
772.2
774.2
774.39
774.6
764.9
766.1
770.1
771.5
762.5
762.3
762.0
776.4
766.2
763.6
765.1
_PERINATAL CONDITIONS
Epilepsy
Epilepsy, Grand Mal
Spiepay, Petit Mal
pilepsy, Temporal Lobe
Headache
Headache, Tension
Hydrocephalus
Hyperventilation, Psychogemc
Meningitis, Bacterial
Meningitis, E. coli
Meningitis, Hemophilus
Influenza
Meningitis, Pneumococcal
Meningitis, Streptococcal
Mental Retardation, Mild
(IQ 50-70)
Mental Rstardation, Modsrate
(1Q 35-49)
Microcephalus
Migraine
Migraine Vanants
Nailbiting, Thumb Sucking,
Masturbation
Nightmares
Reye's Syndrome
Separation Anxiety Disorder
Sibling Jealousy
Specific Arithmetical Disorder
Spacific Reading Disorder
Stuttering and Stammering
Syncope and Collapse
(Fainting)
Tic Disorder of Childhood,
Transient
ABO Hemolytic Disease
Abruptio Placentae
Anemia of Prematunty
Brachial Plexus Injury at Birth
Breech Delivery
Cesarean Section
Cyanosis or Apnea Originating
in Perinatal Penod
Down's Syndrome
Facial Nerve Birth Trauma
Feeding Problems in Newborn
Fetal Blood Loss
Fetal Distress Before Labor,
Liveborn Infant
Fetal Distress Durning Labor,
Liveborn Infant
Forceps Delivery
Fracture Clavicle
Hemorrhage, Intraventricular
Hemorrhage, Subarachnoid
Hypsrbilirubinemia of
Prematurity
Hyperbilirubinemia, Breast
Milk Jaundice
Hyperbilirubinemia, Transient
Neonatal (Physiologic
Jaundice)
Intrauterine Growth Retardation
LGA (Up to 4500 gms, any gest)
Meconium Aspiration
Necrotizing Enterocolitis
Nuchal Cord w/ Compression
Placenta (Twin-Twin)
Transfusion Syndromes
Placenta Praevia
Polycythemia, Neonatal
Post Term, AGA over 42
waaks gest
Precipitate Delivery
Prematurity (1000-2499 gms
and/or 28-37 weeks gest)
Side 2
769 RDS (Respiratory Distress
Syndrome)
773.0 Rh Hemolytic Disease
767.1 Scaip Injures at Birth (Caout,
Chignon, Cephaihematoma)
767.8 Scalpsi Wound Birth Trauma
771.8 Sensis of Fetus, Intrauterine;
Sapticemia of Nawborn
764.0 SGA without Fetal Mairutrition
767.0 Subdural or Cerebral
Hemorrhage
798.0 Sudden Infant Death
Syndrome
77.3 Swallowed Maternal Blood
775.1 Syndrome of Infant of a
Diabetic Mother
770.6 Transitory Tachypnea
of Newborn
RESPIRATORY =.
493.9 Asthma
466.1 Bronchiolitis, Acute
466.0 Bronchitis, Acute
431.8 Bronchitis, Chronic,
Unspecified
485 Bronchopnaumonia
786.2 Cough
464.4 Croup Syndrome
470 Deviated Nasal Septum,
Acquired
786.0 Cyspnea
464.3 Epiglottitis. Acute
474 1 Hypertrophy of Tonsils
and/or Adenoids
487 1 influenza with Respiratory
Manifestations
464.0 Laryngitis, Acute
471.9 Nasal Polyp
460 Nasopharyngitis (Common
Cold), Acute
462 Pharyngitis. Acute
482.9 Pneumonia, Bactenal,
Unspeciited
483 Pneumonia, Mycopiasma
480.9 Pneumonia, Viral, Unspecified
477.9 Rhinitis, Allergic
461.9 Sinusitis, Acute
473.9 Sinusitis, Chronic
464.1 Tracheitis. Acute
786.09 Wheezing
“SIGNS & SYMPTOMS.
783.2 Abnormal Weight Loss
783.0 Anorexia (Not Anorexia
Nervosa)
786.9 Breath Hoiding Spells
786.5 Chest Pain
782.5 Cyanosis (Not Newborn)
780.6 Fever of Unknown Ongin
789.1 Hepatomegaly
795.8 HIV - Positive Serology or
Culture (asymptomatic)
783.3 infant Feeding Problems
(Not Newborn)
782.4 Jaundice (Not Newborn)
783.4 Lack of Expected Development
(Failure to Thrive,
Short Stature)
780.7 Malaise and Fatigue
781.6 Meningismus
782.61 Palior
782.7 Petechiae
782.1 Rash, Nonspecific Skin
Eruption, Exanthem
789.2 Splenomegaly
785.6 Swollen Glands
|
| DECIMALS ON
PM 160
Accassnry Nipple
Acne
Alopecis
Boil, Carbuncle, Furuncie
Calluivtis, Site Unspecifie’
CorrvCaliue
Dermatitis, Contact,
Unsp=aifind Cause
Dermetitis, Detergent
Dermatitis, Diaper
Dermatitis, Rhus (Poison ivy,
Oak, Sumac)
Dermatitis, Seborrheic
Eczema
Erythema Multiforme
Felon
Granuloma. Umbilical Corda
Heat Rash
impetigo
ingrown Nail
Nevus, Nonneoplastic
Paronychia of Finger
Paronvchia of Toe
Pityriasis Rosea
Sunburn
Urticana, Unspecified Type
Vascular Harnariomas
(Strawberry Nevus.
Port ¥/ine Stain)
920 - 924
Rios TE fn WIN NA oP
-. DISLOCATION:
“=
910 - 919
(abrasions, blisters, bites, splinters. etc ©
CORRECTICNS
Metaboiic/Endocrine
775.3 Hyperthyroidism,
neonatal
The International Classification of Diseases, 9th Revision,
Clinical Modification, Volumes 1, 2, and 3, published by the U.S.
Dept of Health and Human Services. may be purchased from:
The Superiniendent of Documents
U.S. Government Printing Office
Washington, D.C. 20402
202/783-3238
AMC niirlimratian #8 (DUC aN_192Nn
For additional copies, contact:
Amencan Academy of Pediatrics
Department of Publications
- 141 Northwest Point Blvd.
P.O. Box 927
Elk Grove Villiage, IL 60009
Price $5.00 (members)
PAA RAN lnman mmmamara
——.
hy .
v I wr--nvie
30 NOT ENTER |
Child Health
and
Disability Prevention Program
| January 1991
Gordon H. Cumming, Ph. D., Chief
Child Health and Disability Prevention Branch
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH SERVICES
CHDP PROVIDER MANUAL
TABLE OF CONTENTS
CHAPTER
001 GENERAL INFORMATION
100 CHDP PROGRAM OVERVIEW
101 Program Definition
102 Services
103 Program Organization
200 PROVIDER PARTICIPATION
201 Introduction
202 Becoming a CHDP Provider
203 CHDP Provider File
204 Types of Providers
204.a A Health Assessment-only Provider
204.b A Comprehensive Care Provider
Use of Nurse Practitioners and Physicians’ Assistants
(Nonphysician Practitioners)
Role of CHDP Providers
206.a Scheduling CHDP Examinations
206.b Obtaining Consent
206.c Required Assessment procedures
206.d Immunizations
206.e Counseling on Results of Assessment
206.f Referring for Dental Services
206.¢ Referral and Follow-up
207 Certifications for School Entry
208 Withdrawal of Provider Status
CHDP SCOPE OF PROGRAM BENEFITS AND CLIENT ELIGIBILITY
301 Introduction
302 Residency Requirements for feimbursed Services
303 Benefits for Groups Eligible for ChDP Program Benefits
303.a Benefits for Medi-Cal Eligible Children and Youth
303.b Benefits for Non-Medi-Cal-Eligible Children and
Youth From Low-Income Families
303.c Benefits for Head Start/State Preschool Children
304 Documentation of Eligibility
304.a Medi-Cal Eligibility
304.b State-Funded-Eligibility
CHDP PROVIDER MANUAL
TABLE OF CONTENTS
CHAPTER PAGE
300 CHDP scope of program benefits and client eligibility (Cont.)
305 EXCIUACH SEIVICES .....cvsevnsvisnisrrrrssstsssssssrssnsssnrinserronsasnssssssassssssrssesnssenssnsres 300.4
305.a. Diagnostic and Treatment SErviCes............ccceeeverinimminiiinniiii. 300.4
305.0 IN Patient SeIVICES ......coveivsisriviressrsrsessresesessnsesssssnsssesssssrasssreserers 300.4
400 REIMBURSEMENT POLICIES ........ciiiiiiiiiieiniinirinsientresrnstnssssesstssisisasernaenes 400.1
AO] OVETVIEW oor. cies rississansusansonsnsarsss sndtsnssrsassasiednvensnssssnssttsttrnesssasnrinsaratsarrs sy 400.1
FO IIS iii vs siere Hiner ieearsntnrasnvsesnensnns wuss sssdhneenneiesonspinsnbonsssvosireissvasasioinis 400.1
Computer Media Claim Billing... 400.1
402 Reimbursement POHCIES.........cocoviiiiiiiiiiiieiiiiiiiii issn scsr eins ss csansesan, 400.2
402.2 Billing ReStriCtONS. .......ooiiiiiiiiiiiii 400.2
402.b Billing LIMitations..........coiiiiiiiiiiiiiiiiiii ces 400.4
A073 ProVIACT FEES .......coiveverransersnsnssrsesssssnsinssanssrsrernnssssussbsnsssssssssivessssnorerssnsprs se 400.4
404 Payment for Services Rendered...........cooooeiiiiiiiiiiiiininnnn 400.4
A005 SNATE Of OSE... cris ii tein sesadarinissvavarensisnssenssssossusssnnnshasess ast ss sou pus asssnvees sreny 400.5
406 Other COVETALE .....ccciuuieriiurirurieiirenttrsriattiitesietestssttsassastrsressettteststassananees 400.5
500 PROCESSING OF CLAIMS ......ccciviiiiiiiiieiretetriinissesssnstasesessesssssssenssestnsnssnnssens 500.1
501 Introduction
BOD CVCTVIZW «iio ivnisenes serasissrunsevons ver savmransasnanss stsbiessnerstiness ss ¥asnne sus avnnsu vee sssvnaes 500.1
503 ManuUAL PYE-EIl.......c.ccririsvisnitemsarsnssasssssrsssasedseensnsnnsnsnssssassespsonsinerans sovaie 500.2
BS a OVOIVIBW i... ivi cirnsericnanvinermasnssdonnrvsnsnshustsenssnsnonghohtnsnssssssentpbisassnssnsse 500.2
B04 CrIHCAl El coi. iirc ihiiinesnitinsssssinsshansnssssshiunints soinsronsssansonsehiyhusssninsns sires 500.3
BOA.2 OVEIVIEW .....coirisiscinevorsnsarsressnsssnstrsstsisesinvhnisvnsens 34189848 a1 rantrnsnesersanrs 500.3
504.b Issuance of Provider Corrections Request (PCR) ...........ccceeeiiiennniins 500.3
504.c Provider Action ON PCRS......c.cceiuiiieiiiriietitnrirtneninnienereteriiitanenanns 500.3
504.d Claim Denials Issued After PCRS.......cc.ccccieiinriniinieniniennineresiensiccenne. 500.3
504.e Denial of Claims Without Issuance of PCR........cccciiiniiiniiiniinnnnnnn. 500.4
504.f Process for Provider to appeal the Notice of Claim Denial
issued from the Critical Edit..........cccciniiniiiiiinnnn nian, 500.4
505 Fee Adjustment Edit .........cooooiiiiiiiiiii 500.5
BOB. OVOIVIEW oui reiitittniresnsinnisssniessrnenstyns sass snnnssssssnsrssases ests tsiterevsnenres as 500.5
505.b Process for Provider to Appeal any Fee Adjustments...............ceeee 500.5
506 History Edit/Extended Visit Edit .........cooooiiiiiiiiiminin 500.6
CHDP PROVIDER MANUAL
TABLE OF CONTENTS
CHAPTER PAGE
507 HUSIOTY Eile... o0snisicirinrsorrisnistnisesrinsinassnssrssvnssnesosesstonsnsnsionroranesprsonsonsonse 500.6
B07. DUDHCAIE SEIVICES ..ccociorrisivrnsivsrisnsisitsnissssboinssiasssiinivinivonressrnsrsestos 500.6
507.b Services Outside Periodicity Schedule ..........ccccviiniinirervernseriernesrises 500.6
507.c Process for Appeal of Claims Totally or Partially Denied by the
HUSHOTY Elita. outeeosssesnessssnssrnssnsspusentnscrespnorsernonssaioresnnasosnes verso 500.7
508 Extended VISIt FEldit......cocstoescinessrstiins sins stapses stniststirse sesensnssnrnssisonssnesnnvere 500.8
508.a Process for Appeal of Claims When Fee is Cut From "Extended
Visit” 10 a "Routine VIS" Rate .....coco vores crmnrririni inssirisiarisinnsinpereine 500.8
509 Summary of Process for Claim APPEAIS..........c.ccrcrramsrirsrvicrsrearessnsirnes srervans 500.9
BIO REMIANICR AGVICE. . ouvir coinrisroriserssrisestitnns soranssiianit vanpaseghsrevsnsvsens ses isnsen sreavnns 500.11
511 Requesting a Balance Due Payment... ...... ccc omnniscrsinssesrrnsssesierressssearnss 500.15
B12 Tracing CIAIIMS. ......vorcornsaristasnsissisivannssncrbrernrsnctnnerrssdinrssiisinsssiassusssnssenssnss 500.15
513 Retroactive Payment fOr VACCINE... ...ccorsarecriisessisiterarensissrsnsnssvisbresnssnrarsanes 500.16
514 Provider Returning OVEIPAYINIEILS .....ccccocsrerererssererssnsresuserservenssssisrssrsnssrans 500.16
515 Requesting Verification of Payment or a Replacement Check...................... 500.17
APPENDICES
CHDP PROVIDER MANUAL
APPENDICES
Appendix A: Sample of Forms
e CHDP Consent Form (PM 211) $00 000000000000 000000000000 0000000000000 0E0000000OcEISEOEIOIoanccsassccascnosnse
e CHDP Confidential Referral/Follow-Up Report (PM 161) $0 esc esessssscesssessnsesenssensse
e Report of Health Examination for School Entry (PM 171A) @ecesessssesecsessssessessnsans
Appendix B: Provider Correction Requests
e Provider Correction Request Messages 9000080800090 0000000000 00000000C000E000000000Rc000R00OC0SERTSEOSES
0 REY 10 COMENE teers ccrrrsternsnssirrassnsirmmssassnsisenntnnrsusnssassntssnsasisesssssnsrs anisms
®: Provider Correction Request SAMPLE .........ccoreririnensrsrsntsinssenririsronsrnsissssresernsnss
e Example of Completed Provider Correction Request
Appendix C: Claim Denials
¢ Denial Messages and Explanations... ....cc.vesscerenesnessorerssnssrssssonivsssesrnesins sess
0 "Notice Of Glatt Denial ....civeiii iiiinrepitassrsrres sorunsarssnsssvinessasrassiisssssnsns ssarvnnnsy
eo Denial Letter for Duplicate Services $0 E0839 80 0000000000000 00000EesNEceresincenessnssosnscsecssassaccnscscnss
eo History Edit Denial Letter EE EE EE EEE EE EE EE a a a a
e History Edit Partial Denial Letter 80 000 S00 S00 0E00000000000000 0000000000000 000000E0CEsOIOCIIOIOEIOTTIOOROEIBOEEOEOOTIEATODES
e¢ Manual Edit Letter $9 000 0000000800800 0800000000000 0 rIaTtissesssssieserestsctsesncoetosccesncosssssssnsssccssnsnsnsses
Appendix D: Provider Status and Payment Appeal Process EE EY
Appendix E: Medi-Cal Card Code References
eo Guide to CHDP Eligibility
Verification Requirements for Medi-Cal Aid Types 000000005 000000000000000000CCERRIESIRRITSTS
e Medi-Cal Aid Codes and Definitions 0 000 e00E000000000E00000c00000000000000000000000000000OCOCOCEIOSRTRSRAITSBTGES
eo Other Coverage Codes 000000 000000088000 000000000 080000000 00GCE0CO0 CCC O0OCOITEOCERTCO0OC0CIO0CCO0CO0G0CCCO0IOI0CEEO00CTCIRCEGETRIRSEITEITOSTSITESD
e Health Care Plan Codes 0 800 0008080000000 00800000000 000000000000 000E00000c0e0cCeecaencencesesscssssecncoesssscscos
Appendix F: Table of Reportable Events Following Vaccination Secs ses essnscecsvensesssessssnene
CHDP PROVIDER MANUAL
Chapter
GENERAL INFORMATION 001
This provider manual interprets the policies and procedures of the Child Health and Disability
Prevention (CHDP) program. It is designed as a reference document and contains basic
information about provider responsibilities, the services which can be provided to eligible
children and youth, and how to be reimbursed for CHDP program services.
The CHDP Medical Guidelines and the PM 160 Instructions for billing on the CHDP
Confidential Screening/Billing Report are a part of this manual.
Revisions and additions which will be sent from time to time should be incorporated into the
manual. All revisions will be accompanied by a notice which explains what pages should be
deleted from the manual and where the revision is to be placed.
ANY QUESTIONS OR COMMENTS ABOUT CHDP PROGRAM POLICY AND PROCEDURES IN
THIS MANUAL MUST BE DIRECTED TO YOUR LOCAL CHDP PROGRAM LISTED BELOW.
Local Program:
Address:
Contact Person: Telephone:
Nata 11 /7QN Dede YY ND
CHDP PROVIDER MANUAL
Chapter
CHDP PROGRAM OVERVIEW 100
Section
PROGRAM DEFINITION 101
The CHDP program is a public health program providing reimbursements to public and
private providers for complete health assessments for the early detection and prevention
of disease and disabilities in children and youth. One of the program goals is to
assure that eligible children and youth have access to ongoing health care.
The CHDP program provides services to the following groups (See Chapter 300 for Scope
of Benefits):
1. Medi-Cal eligible beneficiaries from birth through 20 years of age.
2. Non-Medi-Cal eligible children and youth from birth through 18 years of age whose
families meet the required income standards.*
3. Children attending Head Start and State Preschool programs.
SERVICES 102
The CHDP program provides the following services:
1. Assistance in obtaining health assessment and dental services for the eligible
population.
2. Reimbursement to providers for complete health assessment services which include
a health history; physical examination; dental assessment; nutritional assessment;
developmental assessment; immunizations; vision and hearing testing; tuberculin
tests: laboratory tests; appropriate health education, including the harmful effects of
the use of tobacco products and exposure to secondhand smoke; and anticipatory
guidance as delineated in the CHDP program Medical Guidelines.
3. Assistance to patients/families in obtaining diagnostic and treatment services that
were found to be needed during the health assessment.
4. Assistance to Medi-Cal eligible pregnant women in obtaining prenatal care.
PROGRAM ORGANIZATION 103
The CHDP program is administered and financed by the State Department of Health
Services (DHS) and operated by local health departments. Every county health
department in the State and the City of Berkeley operates a CHDP program. These local
programs are responsible for day-to-day operation of the program including provider
recruitment and approval, liaison with local schools, education and outreach to eligible
families, and assistance to families in obtaining services (case management).
The CHDP program is also responsible for assuring that children entering kindergarten
and first grade have access to certification of a health assessment or a parental waiver.
The school entry program is jointly administered with the Department of Education.
* Current income standards are available to providers and distributed by local CHDP programs as changes occur.
CHDP PROVIDER MANUAL
Chapter
PROVIDER PARTICIPATION 200
Section
INTRODUCTION 201
CHDP services are provided by private physicians, prepaid health plans, primary care
centers, clinics, and other public and private agencies or organizations. All CHDP health
assessments must be performed by or under the supervision and responsibility of a
physician licensed to practice in California. These services must be provided as specified
in the CHDP regulations and Medical Guidelines.
BECOMING A CHDP PROVIDER 202
All physicians, groups, clinics, or organizations desiring to become CHDP providers must
apply to the CHDP program in each county in which they wish to provide services
and agree to abide by the CHDP program guidelines, policies, procedures, and regulations
and any other guidelines established by the local CHDP program.
Different provider numbers are needed for each site of practice. Providers must use
their assigned Medi-Cal provider number or a number assigned by the State if they are
not a Medi-Cal provider.
Prepaid health plans (PHPs) who are under contract to the State to provide care to
Medi-Cal enrollees are granted CHDP Providership by the State and must, according
to their contract, offer and provide complete CHDP services for all enrollees from
birth through age 20 according to the CHDP Medical Guidelines.®* PHPs may also
apply to local CHDP programs to become CHDP fee -for-service providers for persons not
enrolled in their plan. They must include in their application a description of their
subcontractors and those who contract with the subcontractors.
Agencies or organizations (other than physicians and physician groups) requesting
approval to become CHDP providers must comply with California State statutes governing
organized medical practice. Information, including proof of licensure, must be provided
about the qualifications of physicians and other persons under physician supervision who
are to conduct various parts of the health assessment. They must also provide any other
information requested by the local program director and agree to comply with the
established CHDP standards for health care.
The agreement with the local program to participate as a provider outlines program and
provider responsibilities.
ANY CHANGES IN PROVIDER INFORMATION SUCH AS AN ADDRESS OR PROVIDER
NUMBER CHANGE MUST BE IMMEDIATELY REPORTED TO LOCAL PROGRAM STAFF.
* See Appendix for a list of PHPs under contract to the State.
CHDP PROVIDER MANUAL
Chapter
PROVIDER PARTICIPATION 200
Section
CHDP PROVIDER FILE 203
When enrolling new providers or when any provider information changes, the local
program is responsible for submitting a form (PM 177) to the State CHDP Branch to
update the CHDP Provider File. This form includes the date a new provider can start
giving CHDP services or the date the information changes are valid.
Notices will be sent from the State to new providers with a copy to the local CHDP
program confirming their enrollment on the CHDP Provider File. NEW PROVIDERS
SHOULD NOT SUBMIT CLAIMS UNTIL THIS NOTICE IS RECEIVED.
Current providers will also be sent a notice confirming information changes to the current
CHDP Provider File. PROVIDERS FOR WHOM CHANGES IN INFORMATION ARE
SUBMITTED SHOULD EITHER HOLD THEIR CLAIMS OR USE THE OLD INFORMATION
UNTIL THEY RECEIVE NOTICE THAT THE CHANGES ARE IN THE CHDP PROVIDER
FILE,
TYPES OF PROVIDERS 204
There are two types of CHDP providers: the "Health Assessment-only” provider and the
"Comprehensive Care” provider. Different fee schedules are established for each type of
provider.
The "Health Assessment-only” provider agrees to provide all required health assessment
services as defined in the CHDP Medical Guidelines for the age and sex of the patient and
refers the patient to another provider for any needed diagnostic and treatment services.
The "Comprehensive Care" provider agrees to provide all health assessment services as
defined in the CHDP Medical Guidelines for the age and sex of the patient and any needed
diagnostic and treatment services and must be avilable to the patient for all ongoing
medical care.
A "Health Assessment-only" Provider Shall: 204.a
1. Provide health assessment services according to the CHDP specified procedures and
periodicity schedule (see the CHDP Medical Guidelines). This includes all necessary
immunizations and referral for diagnostic and treatment services, and
2. Maintain records for each CHDP patient which include, at a minimum, the health
history, immunization record, summary of findings, and health education and
anticipatory guidance given.
CHDP PROVIDER maar
Chapter
PROVIDER PARTICIPATION 200
Section
A Comprehensive Care Provider Shall: 204.b
1. Meet the requirements of the "Health-Assessment-only" provider status.
a. Provide health assessment services according to the CHDP specified procedures
and periodicity schedule (see the CHDP Medical Guidelines). This includes all
necessary immunizations and referral for diagnostic and treatment services, and
b. Maintain records for each CHDP patient which include, at a minimum, the
health history, immunization record, summary of findings, and health education
and anticipatory guidance given.
2. Be a Medi-Cal provider on "active status" with the Medi-Cal program. (A separate
Medi-Cal number is needed for each office site of practice.)
3. Assume the overall follow-up case management responsibilities for the patient by:
a. Initiating diagnosis and treatment or providing referral with follow-up for all
suspected conditions needing definitive diagnosis and possible treatment.
b. Providing continuing preventive health services as outlined in the CHDP Medical
Guidelines.
4. Maintain a health record for each patient.
5. Be available as a source of primary care on a continuing basis to the patient in the
event that subsequent medical services are requested. This includes arranging
coverage for services "after hours" so that continuity of care is maintained.
USE OF NURSE PRACTITIONERS AND PHYSICIANS' ASSISTANTS 205
(Nonphysician Practitioners)
Nurse practitioners and physicians’ assistants employed by CHDP providers may perform
CHDP services. They and their employers must comply with all local guidelines and with
all California State statutes governing the practice of nurse practitioners and physicians’
assistants. Fees charged the State for services given by nonphysician practitioners may
be the same as their physician employer.
A physician who is a provider of child health services shall be available to
non-physician practitioners at all times while they are providing services and is
responsible for the services they provide. The physician must be a CHDP provider
in the county in which the non-physician practitioner provides services.
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Section
ROLE OF CHDP PROVIDERS 206
Scheduling CHDP Examinations 206.a
1. Providers may receive a call from a patient or a parent/guardian of a child requesting
an appointment for a CHDP exam.
2. Providers may be contacted by CHDP program staff in the local health department or
by a worker in the local welfare department to make an appointment for someone
who has requested CHDP services. The person may have identified the provider as
his/her physician.
3. Providers should identify CHDP program eligible persons in their practice (see Scope
of Benefits, Chapter 300); and:
a. When an eligible person comes in for a minor health problem and has not had a
CHDP exam according to the schedule, the provider may give the CHDP exam as
well as treat the problem (see Reimbursement Policies Chapter 400).
b. Make appointments for CHDP exams for Medi-Cal and low income CHDP eligible
patients in their practice.
4. Providers must give regular appointments for periodic examinations according to the
CHDP periodicity schedule (see CHDP Medical Guidelines) to children under age 2
and inform all others when their next examination is due.
Obtaining Consent 208.b
Providers must obtain the voluntary written consent of the patient or parent/guardian
BEFORE performing a health assessment. Consent is also required for any release of
information regarding the patient. The CHDP program has a standard Consent Form
(PM 211) (see appendix) available to providers who do not have their own consent form for
release of information.
The back of the parent copy of the PM 160 informs the parent/guardian/patient
where copies of the claim form are sent.
Minors (patients under 18 years of age) may provide legal consent if:
1. The minor is emancipated;
2. The minor is or has been married;
3. The minor is a member of the military forces; or
4 Parental consent for the service is not necessary under State or federal law.
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Required Assessment Procedures 2086.c
Unless medically contraindicated, deemed inappropriate by the provider, or refused by the
person, health assessments shall include:
1.
2
10.
Health and developmental history.
Unclothed physical examination including assessment of physical growth.
Assessment of nutritional status.
Inspection of ears, nose, mouth, throat, teeth and gums.
Vision screening.
Hearing screening.
Tuberculin testing and laboratory tests appropriate to age and sex, including tests for
anemia, diabetes, and urinary tract infections.
Testing for sickle cell trait and lead poisoning where appropriate.
Immunizations appropriate to age and health history necessary to make status
current.
Anticipatory guidance and health education appropriate to age and health status
including the harmful effects of the use of tobacco products and exposure to
secondhand smoke.
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Chapter
PROVIDER PARTICIPATION 200
Section
Immunizations 208.4
Requirements for Providers Using Immunization Assistance Program (IAP) Vaccine.
Public health department clinics using Immunization Assistance Program (IAP) vaccines
and giving IPV, Hib, OPV, DTP/Td/DT, or MMR must use the important information
statements (risk/benefit forms) provided by IAP. In addition, non-profit clinics, e.g.,
community based organizations, schools, Head Start Centers, etc., using IAP vaccines
obtained through local health departments must agree to and sign the "Outside Provider
Agreement For Receipt Of State-Supplied Vaccine”. One of the requirements in this
agreement is that vaccine providers must follow approved procedures (described in the
agreement) for informing patients about vaccine benefits and requests.
Immunization Record Keeping for All Providers
The National Vaccine Injury Act of 1986 (PL 99-660) with 1987 amendments effective
March 22, 1988 imposes requirements on all public and private vaccine providers
(i.e., physicians, clinics, etc.) to keep records and to report adverse events for certain
vaccines. The vaccines and toxoids are those for diphtheria-tetanus-pertussis
(DTP/Td/DT), oral polio (OPV), inactivated polio (IPV), and measles-mumps-rubella
(MMR, MR, and single measles, mumps, or rubella).
Vaccine providers must record on the patient's chart or in the clinic's permanent
immunization record (or in a permanent office log or file) the following: patient name,
address, date of birth, age at time of immunization, name and title of person
administering the vaccine (e.g., S. Smith, R.N.), type of vaccine(s) given, date of
immunization, site of immunization, vaccine manufacturer, vaccine lot number. "Address"
means address of the clinic/office/hospital where the vaccine was administered. If these
records are kept in a common file or log, a separate address does not have to be included
for each entry. In addition, the record or log is to be retained by the vaccine provider for a
minimum of 10 years following the calendar year in which the vaccine(s) was
administered.
The California School Immunization Law also requires vaccine providers to give patients
or their parents a record of immunizations administered. Local health departments
provide the yellow California Immunization Record (CIR) for this purpose, free of charge.
Concerning adverse events following an immunization, anyone providing the vaccines
must report specified illnesses or adverse events that occur following certain vaccines
within defined time intervals as indicated in the Table of Reportable Events Following
Vaccination (See Appendix F-1). Medical providers using IAP vaccine must report to the
local health department on the Vaccine Adverse Event Reporting System (VAERS) form.
Supplies of this form are available from the local health department. Also, all private
physicians and clinics using vaccines they purchase themselves are required to report
adverse events on a VAERS form which is postage-paid and goes to another location.
Copies of the VAERS form to be used with non-IAP supplied vaccine, can be obtained free
of charge by writing to:
VAERS
c/o ERC BioServices Corporation
1055 1st Street, Suite 130
Rockville, Maryland 20850-9788
Telephone: 1-800-822-7967
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Section
Counseling on Results of Assessment 2086.¢
AN EXPLANATION OF THE RESULTS OF THE EXAMINATION AND A COPY OF THE
PM 160 MUST BE GIVEN TO THE PARENT/GUARDIAN/PATIENT AT THE TIME OF
ASSESSMENT.
Referring for Dental Services 206.1
ALL CHILDREN AND YOUTH WITH DENTAL PROBLEMS MUST BE REFERRED
DIRECTLY TO A DENTIST FOR CARE.
ALL MEDI-CAL ELIGIBLE CHILDREN AND YOUTH AGE THREE (3) AND ABOVE MUST
BE REFERRED FOR PREVENTIVE DENTAL CARE TO A DENTIST THAT ACCEPTS
DENTI-CAL REGARDLESS OF WHETHER OR NOT A DENTAL PROBLEM IS DETECTED.
Referral and Follow-up 206.¢
When a "Comprehensive Care" provider has a patient needing diagnostic and/or treatment
services, providers are to help the patient obtain the services they cannot directly provide.
Assistance can be requested from local CHDP program staff in contacting patients and
helping them with appointments.
When a "Health Assessment-only” provider has a patient requiring referral and/or follow
up, the provider should, when possible, give the patient a list of at least three (3)
appropriate sources of care.
Local CHDP program staff may also provide follow up to assure that diagnostic and
treatment services are initiated when they receive the copy of the PM 160 which indicates
these services were needed.
Use of Referral Form
When any provider refers a patient to another source of care, the referral must be noted
on the PM 160 and on either the "Confidential Referral/Follow-up Report” (PM 161)
(See appendix), or an alternate referral form approved by the local program.
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CERTIFICATION FOR SCHOOL ENTRY 207
California State law requires that children entering first grade must provide their schools
with a certificate documenting that they have had a health assessment or a waiver of the
assessment signed by the parent or guardian. The assessment may be done 18 months
prior to or within 90 days after entrance into first grade. It is the policy of the CHDP
program and local schools to urge parents to get their child's health assessment upon
entry into kindergarten.
Documentation for School Entry
1. Certification of Health Assessment (PM 171A) (See Appendix). The provider shall give
the parent/guardian of a child entering kindergarten or first grade a certificate which
documents that the child has received the appropriate health assessment
procedures. The certification is required for all children whether or not the cost of
the health assessment is reimbursed by the State.
2. Certification Without Health Assessment
A child's personal physician may certify a child for school entry without a health
assessment if the child has received a physical examination and ongoing
comprehensive medical care from that physician during the 18-month period prior to
or within 90 days following entrance into the first grade. The medical care must
have included all the applicable health assessment procedures.
3. Waiver of Health Assessment (PM 171B)
If a health assessment is refused by the parent or guardian, the parent or guardian
must submit a waiver to the school.
Contact the local CHDP program for a supply of health certificates.
WITHDRAWAL OF PROVIDER STATUS 208
Provider status may be withdrawn by the local CHDP Director if:
1. The provider is not performing the services as agreed upon or the provider is not
complying with the standards established by the State or the local program.
2. The Department of Health Services (DHS) suspends that provider from participation
in and/or reimbursement by the Medi-Cal program.
3. See the Appendix for appeal of any action on provider status taken by a local
program or by the State.
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CHDP PROVIDER MANUAL
Chapter
CHDP SCOPE OF PROGRAM BENEFITS AND CLIENT ELIGIBILITY 300
INTRODUCTION
The CHDP program reimburses outpatient preventive health services provided to:
1. Medi-Cal eligible beneficiaries from birth through 20 years of age.
2. Non-Medi-Cal eligible children and youth from birth through 18 years of age whose
families meet the required income standards*
3. Children attending Head Start and State Preschool programs.
RESIDENCY REQUIREMENTS FOR REIMBURSED SERVICES 302
A person who is residing in California and (1) is on Medi-Cal or (2) otherwise eligible for
CHDP services, is eligible to receive these services in any California county regardless of
the person's county of residence. United States citizenship is not a criterion for eligibility.
BENEFITS FOR GROUPS ELIGIBLE FOR CHDP PROGRAM SERVICES 303
Benefits for Medi-Cal Eligible Children 303.a
Health Assessment Services
Persons from birth through 20 years of age certified Medi-Cal eligible by a county welfare
department are eligible to receive initial and periodic CHDP reimbursed health assessment
services according to their age, sex, and health history if they are not enrolled in a Prepaid
Health Plan (PHP) where preventive health services are a covered benefit. PERSONS
COMING IN FOR CARE WHO HAVE NOT RECEIVED ALL THE RECOMMENDED
PROCEDURES FOR AN EARLIER AGE GROUP SHOULD BE BROUGHT UP TO DATE AS
APPROPRIATE.
Diagnostic and Treatment Services
Diagnostic and treatment services will not be reimbursed by the CHDP program. Medi-
Cal covered diagnostic and treatment services for Medi-Cal eligible persons are
reimbursable through the Medi-Cal program. To be reimbursed for such services, the
provider must be a Medi-Cal certified provider and bill the Medi-Cal program. For further
clarification, see Chapter 400, Section 402 a.
Providers may request the assistance of the local CHDP program staff in contacting
families and helping them with appointments.
* Current income standards are available to providers and distributed by local CHDP programs as changes occur.
CHDP PROVIDER MANUAL
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Section
Benefits for Non-Medi-Cal-Eligible Children and Youth From Low-Income Families 303.b
Health Assessment Services
Children and youth from birth through 18 years of age, who are not certified Medi-Cal
eligible, are eligible to receive initial and periodic health assessments reimbursed through
the CHDP program if their family income is at or below 200% of the federal poverty level
and they are not enrolled in a Prepaid Health Plan where preventive health services are a
covered benefit.
Diagnostic and Treatment Services
Diagnostic and treatment services will not be reimbursed by the CHDP program.
Non-Medi-Cal eligible children and youth needing these services may have insurance,
may be referred to appropriate agencies such as California Children Services (CCS),
Regional Centers for the developmentally disabled, etc., or may be eligible for reimbursed
services through their county of residence with monies available from the Tobacco Surtax
Fund (Proposition 99).
Providers may request the assistance of local program staff in contacting families and
helping them with appointments and obtaining information on how diagnostic and
treatment services may be reimbursed.
Benefits for Head Start/State Preschool Children 303.c
Health Assessment Services
All Head Start and State Preschool children are eligible for reimbursed CHDP health
assessment services appropriate for their age and health history if they are not enrolled in
a Prepaid Health Plan where preventive health services are a covered benefit.
A special PM 160 HSP which will be brought by the parent or guardian to the CHDP
provider's office must be used in order to be reimbursed for this assessment. The child's
name and grantee or project number must be entered on the PM 160 HSP by the Head
Start or State Preschool program (see the PM 160 Instructions) before giving it to the
parent or guardian to take to their provider. A PM 160 HSP claim will not be reimbursed if
the grantee number is not entered. Do not accept a PM 160 HSP if this information
has not been entered. Contact the local CHDP program.
Diagnostic and Treatment Services
Diagnostic and treatment services will not be reimbursed by the CHDP program.
Non-Medi-Cal eligible children needing these services may have insurance or should be
referred to appropriate agencies such as California Children Services (CCS), Regional
Centers for the developmentally disabled, etc., or may be eligible for reimbursed services
through their county of residence with monies available from the Tobacco Surtax fund
(Proposition 99).
CHDP PROVIDER MANUAL
Chapter
CHDP SCOPE OF PROGRAM BENEFITS AND CLIENT ELIGIBILITY 300
Section
Diagnostic and Treatment Services (Cont.)
Medi-Cal covered diagnostic and treatment services are reimbursable through the
Medi-Cal program for Medi-Cal eligible children. To be reimbursed for such services, the
provider must be a Medi-Cal certified provider and bill the Medi-Cal program.
Providers may request the assistance of local CHDP program staff in contacting families
and helping them with appointments and obtaining information on how diagnostic and
treatment services may be reimbursed.
DOCUMENTATION OF ELIGIBILITY 304
Medi-Cal-Eligibility 304.2
Persons are not considered to be on Medi-Cal or Medi-Cal eligible until they have been
certified by a county welfare department as Medi-Cal eligible.
Children and youth eligible for emergency or pregnancy related services only with their
Medi-Cal card are not considered to be Medi-Cal eligible for CHDP services. Patients with
this type of Medi-Cal coverage may qualify for CHDP service reimbursement as
non-Medi-Cal eligible patients if all other requirements are met (see Section 304.b).
A family who has a share of cost (SOC) obligation for medical expenses is not considered
Medi-Cal eligible until they have met their SOC obligation for the month of service (see
Section 405) and have returned the form to a county welfare department and been
certified Medi-Cal eligible.
Children and youth who have not met their "SOC" may qualify for CHDP service
reimbursement as a non-Medi-Cal eligible patient if all other requirements are met (see
Section 304.b).
THE PROVIDER IS RESPONSIBLE FOR VERIFYING MEDI-CAL ELIGIBILITY OF THE
CLIENT BY CHECKING THE MEDI-CAL CARD OR PROOF OF ELIGIBILITY (POE)
STICKER TO ASSURE THAT THEY ARE VALID FOR THE DATE THE SERVICE IS
RENDERED AND THAT THE CLIENT IS NOT A MEMBER OF A PREPAID HEALTH PLAN
AND IS ELIGIBLE FOR THE FULL SCOPE OF BENEFITS. PLEASE REFER TO THE
APPENDIX FOR INFORMATION ON MEDI-CAL AID CODES AND PREPAID HEALTH
PLAN DESIGNATION AND CODES.
State-Funded Eligibility 304.b
If the provider determines the child is age eligible, is from an income eligible family, is not
on Medi-Cal, and is not enrolled in a Prepaid Health Plan (PHP) which provides preventive
health services, the family may apply for a State-funded health assessment by completing
a "CHDP Eligibility Information Form" (DHS 4073).* Please refer to the PM 160
Instructions.
* Note: A DHS 4073 is not required with a Head Start/State Preschool PM 160 (PM 160 HSP)
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Section
State-Funded Eligibility (Cont.) 304.b
Providers need not prejudge the potential eligibility of families who come for services. A
"CHDP Eligibility Information Form" may be given to each family to allow the
parent/guardian/patient to decide whether or not they want to apply for state-paid CHDP
services. The provider is responsible for reviewing the form qfter completion by the
parent/guardian/patient to determine {f the patient is eligible for a State
reimbursed examination. The provider is not responsible for assuring the accuracy of
the information given by the parent/guardian/patient. THE PROVIDER IS HELD
RESPONSIBLE FOR ASSURING THAT THE PAREN T/GUARDIAN/PATIENT
UNDERSTANDS THE QUESTIONS AND THAT THE FORM IS COMPLETELY FILLED
OUT.
A new eligibility form (DHS 4073) must be filled out and signed by the
parent/guardian/patient for each patient each time any CHDP reimbursed services are
received. The provider must determine {f the child or youth is eligible by
comparing the information given with the CHDP Eligibility Determination Table.
EXCLUDED SERVICES 308
Diagnostic and Treatment Services 308.2
The CHDP program must not be billed for sick care, for diagnostic and treatment services,
for the monitoring of weight gain, or for any conditions including anemia. All
children with serious or chronic conditions should be referred to California Children
Services (CCS) or Regional Centers for diagnosis and treatment since most will be eligible.
1. MEDI-CAL ELIGIBLE CHILDREN AND YOUTH
Medi-Cal-covered diagnosis and treatment services for eligible persons are
reimbursable through the Medi-Cal program. To be reimbursed for such services, the
provider must be a Medi-Cal certified provider and bill the Medi-Cal program.
2. NON-MEDI-CAL ELIGIBLE CHILDREN AND YOUTH
Non-Medi-Cal eligible persons needing these services may have insurance or should
be referred, as appropriate, to agencies such as California Children Services (CCS),
Regional Centers for the developmentally disabled, or may be eligible for reimbursed
services through their county of residence with monies from the Tobacco Surtax
Fund (Proposition 99).
Providers may request the assistance of local CHDP program staff in obtaining information
on how diagnostic and treatment services may be reimbursed.
In Patient Services '308.b
SERVICES PROVIDED IN INPATIENT SETTINGS CANNOT BE BILLED TO CHDF.
® CHDP PROVIDER va@aL
Chapter
REIMBURSEMENT FOR SERVICES 400
Section
OVERVIEW 401
Forms
The confidential Screening/Billing Report (PM 160) is the claim form to be submitted by
providers of CHDP services to the CHDP Claims Unit at Electronic Data System (EDS), the
fiscal intermediary responsible for processing all claims.
Mail To:
Medi-Cal/CHDP
PO. Bax 15300
Sacramento, CA 95851-1300
All forms must be ordered from the local CHDP program. Forms with the provider
information preprinted are available upon request.
Computer Media Claim Billing
CHDP claims for Medi-Cal eligible persons may be submitted using the same media of billing
as Medi-Cal, including tape, diskette and telecommunication. CHDP claims can be submitted
in the same media or on the same transmission with Medi-Cal claims.
Copies of the PM 160 or a similar document containing all the same information that
is on the PM 160 must be sent to the local CHDP program and given to the
parent/guardian/patient.
Providers interested in submitting Computer Media Claims should request the CMC
Provider/Biller Package by calling:
Provider Automation
Electronic Data Systems
(916) 636-1100
Date 11/90 Page 400.1
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Chapter
REIMBURSEMENT FOR SERVICES 400
Section
REIMBURSEMENT POLICIES 402
Billing Restrictions
402.2
1. Providers may not bill the CHDP program and the Medi-Cal fiscal intermediary
for the same health assessment given to the same patient. Billing CHDP and
the Medi-Cal fiscal intermediary for all or part of the same service is a potential
violation of California Administrative Code, Section 51470 (d) (1).
When SIGNIFICANT additional time is spent on treatment services at the time of
the CHDP examination, the provider should bill:
a. CHDP for the history and examination, and
b. Medi-Cal for the additional time spent in initiation of diagnostic and treatment
services using CPT Codes 90030 (minimal), 90040 (brief) or 90050 (limited) or
the appropriate codes for procedures performed in accordance with the
documented amount of professional time expended beyond that billed to CHDP.
It will be considered to be duplicate billing and a potential violation of
California Administrative Code, Section 51470 (d) (0, if any office visit codes
other than 90030, 90040, or 90050 are billed to the Medi-Cal program in
addition to billing the CHDP program for the history and examination. This
prohibition includes NEW PATIENT office visit codes 9000 through 90020, and
established patient office visit codes 90060 through 90080.
2. Only one claim for the same service given to the same patient on the same day may
be submitted to the CHDP program for payment.
3. WHEN CLAIMING FOR AN "EXTENDED VISIT" FOR OTHER THAN NEW PATIENTS
OR PATIENTS NOT ASSESSED FOR TWO YEARS, PROVIDERS MUST INDICATE THE
REASON FOR AN "EXTENDED VISIT" IN THE "COMMENTS/ PROBLEM" AREA OF
THE PM 160.
4. WHEN CLAIMING HEALTH ASSESSMENTS AT MORE CLOSELY SPACED INTERVALS
THAN ARE INDICATED ON THE CHDP PERIODIC APPOINTMENT SCHEDULE, AN
ACCEPTABLE EXPLANATION AND BACKUP INFORMATION OF THE NEED FOR THIS
EXTRA ASSESSMENT MUST BE NOTED IN THE "COMMENTS/ PROBLEMS" AREA
OF THE PM 160. TO ONLY NOTE "MEDICALLY INDICATED" IS NOT SUFFICIENT.
Following are examples of situations that could justify an extra history and physical
exam before the next regularly scheduled exam or justify billing for an extended visit
for a person being seen as an established patient within a two-year period.
a. Significant neonatal problems: low birth weight, respiratory distress syndrome,
or other conditions that required prolonged hospitalization.
b. Immature or inexperienced young mother with her first child or signs of poor
mother-child relationship.
c. Child not showing expected growth and/or development.
CHDP PROVIDER MANUAL
Chapter
REIMBURSEMENT FOR SERVICES 400
Section
Billing Restrictions (Cont.) 402.2
d. Young child with some indication or suspicion of abuse or neglect or failure to
thrive. Diagnostic and follow-up services for these children must not be billed
to CHDP (see number 5 below).
e. Children needing an examination to meet the first grade entry requirement
whose last examination was done at least a year before.
f Children in foster care may have one CHDP examination a year.*
g. Older children needing an exam for camp or contact sports may have one CHDP
examination a year.
h. Children with a significant handicapping condition may have one CHDP
examination a year.*
5. VISITS FOR PATIENTS NEEDING TO BE SEEN MORE FREQUENTLY BECAUSE OF
AN IDENTIFIED CONDITION SUCH AS ANEMIA, OTITIS MEDIA, OR ANY OTHER
CONDITION MUST NOT BE BILLED TO CHDP. THEY MAY BE BILLED TO THE
MEDI-CAL FISCAL INTERMEDIARY, THE PARENTS OR THEIR INSURANCE
CARRIER, REFERRED TO CCS OR REGIONAL CENTERS AS APPROPRIATE, OR MAY
BE REIMBURSED BY THE COUNTY OF THE PATIENT'S RESIDENCE WITH MONIES
AVAILABLE FROM THE TOBACCO SURTAX FUND (PROPOSITION 99).
6. A SCREENING PROCEDURE "RECHECK" IS REIMBURSABLE ONLY WHEN THE
PROVIDER QUESTIONS THE ACCURACY OF A PRIOR TEST RESULT OR WHEN
THE PATIENT HAS FAILED THE VISUAL ACUITY OR AUDIOMETRIC TESTS (SEE
CHDP MEDICAL GUIDELINES) AND CAN ONLY BE REIMBURSED ONCE.
"RECHECKS" CANNOT BE REIMBURSED BY THE PROGRAM FOR ANY OTHER
REASON. PERFORMING ANY PART OF THE HISTORY AND PHYSICAL
EXAMINATION IS NOT CONSIDERED A "RECHECK" AND SHOULD NOT BE BILLED
AS SUCH.
7. A "partial screen" is reimbursable by the CHDP program only when any of the
screening procedures or immunizations are given to complete a recent CHDP health
assessment so that the patient will receive all age-appropriate services. THE
HISTORY AND PHYSICAL EXAMINATION CANNOT BE BILLED AS A "PARTIAL
SCREEN".
A partial screen is also reimbursable when procedures such as hemoglobin or
hematocrit are needed to meet Head Start or WIC requirements for children who have
had a complete CHDP health assessment but are not yet due for another complete
health assessment. The notation "Required by WIC" or "Required by Head Start”
must be entered in the "Comments/Problems” area.
8. The CHDP "Comprehensive Care Provider” fee is to be used by the provider for regular
office patients. "Comprehensive Care" providers who elect to see any patients
on a one-time-only basis shall claim the "Health Assessment-only provider” fee.
These situations occur most often when persons are seen outside of a provider's
office (school setting, com, munity clinic, etc.).
* Under age two years, all children should be seen according to the regular CHDP schedule.
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Chapter
REIMBURSEMENT FOR SERVICES 400
Section
Billing Limitations 402.b
Claims (PM160s) submitted with "Dates of Service" over one (1) year prior to the date of
first receipt by the Claims Processing Unit will not be reimbursed.
PROVIDER FEES 403
The Department of Health Services has established a maximum reimbursement schedule
(the "CHDP Schedule of Maximum Allowances" table) to pay for the screening procedures
completed during a CHDP health assessment (refer to PM 160 Instructions). The
Department has determined that the requirements for a complete CHDP history and
physical examination are unique and, therefore, the provider may be reimbursed up to the
maximum allowance to cover real costs. For all other procedures and for immunizations,
a provider should bill their usual and customary fee or the maximum allowance,
whichever is less. If a provider enters a fee higher than the CHDP allowed maximum, the
fee will be automatically reduced and paid at the CHDP rate. If a provider enters a fee
which is lower than the CHDP rate, the provider will be paid at the lower rate.
THE CHDP PROGRAM DOES NOT REIMBURSE LABORATORIES. LABORATORIES MAY
BILL THE PROVIDER, OTHER INSURANCE, OR THE MEDI-CAL PROGRAM IF THE
PATIENT IS A MEDI-CAL BENEFICIARY. When the laboratory bills the provider, the
provider may bill the CHDP program for the charge made by the laboratory to the provider
plus a fee for any collection and handling of specimens done by the provider. The total,
however, that will be reimbursed will not exceed the "Maximum Allowance” for the
test. (See "Schedule of Maximum Allowances" for handling fee and test fee.)
When a provider uses immunization vaccines provided by the State Immunization
Assistance Program, THE PROVIDER SHALL BILL ONLY THE FEE ALLOWED FOR
ADMINISTERING THE VACCINE (see "Schedule of Maximum Allowances").
PAYMENT FOR SERVICES RENDERED 404
When a CHDP provider bills the Department of Health Services’ CHDP program for
covered health assessment services, the program will reimburse the provider according to
the Department's fee structure. The provider shall accept the amount paid by CHDP as
payment in full for the services rendered. NO CHARGES SHALL BE BILLED TO THE
PATIENT FOR THESE SERVICES, EXCEPT AS NOTED UNDER "SHARE OF COST". THE
PROVIDER SHALL NOT BILL NOR ACCEPT PAYMENT FROM THE PATIENT OR ANY
OTHER PUBLIC OR PRIVATE PROGRAM FOR THESE REIMBURSED SERVICES.
CHDP PROVIDER MANUAL
Chapter
REIMBURSEMENT FOR SERVICES 400
Section
SHARE OF COST 408
A person or family may have a share of cost (SOC) for medical expenses. This SOC is the
amount the person or family must pay or obligate to pay for the the health services they
receive in a given month before they can receive a Medi-Cal card for that month. This
does not mean the person or family must actually pay this SOC amount in order to
receive the Medi-Cal card but only incur the expenses and be obligated to pay this
amount themselves. The SOC is determined by the county welfare department and is
based on the person's or family’s net income in excess of their standardized maintenance
need level established by the State.
The person or family receives a pink form, "Record of Health Care Cost" (MC 1778S), on
which providers record all health services given within the month and their costs. When
the total obligated expenses for services equal or exceed the SOC, this form must be
signed by the person and returned to the county welfare department which forwards it to
the State. If correctly completed, Medi-Cal eligibility is then certified, and a Medi-Cal card
is issued for the month in which the expenses were incurred.
The cost of the CHDP health assessment may be applied to this SOC. The patient must
be billed for that SOC applied to the CHDP health assessment fee. If the SOC is less than
the total CHDP health fee, the remainder of the fee may be billed to CHDP (see PM 160
Instructions for procedure). The patient's "County Identification Number" or "Social
Security Number” and "Check Digit" must be entered on the PM 160.
The State will reimburse the provider for any expenses not used to meet the SOC when
Medi-Cal eligibility has been certified, i.e., the person or family has met their SOC and a
Medi-Cal card has been issued by the local welfare department.
OTHER COVERAGE 406
All perscns enrolled in a Prepaid Health Plan with preventive health services as a
covered benefit must receive their health assessment services from that plan. The
CHDP Program shall not be billed for any services to these persons.
The oo ANN ©
® CHDP PROVIDER man®aL
PROCESSING OF CLAIMS
INTRODUCTION
All CHDP claims (PM 160s) must be submitted for payment to Electronic Data Systems
(EDS). the CHDP fiscal intermediary. Send to:
Medi-Cal/CHDP
PO. Bax 15300
Sacramento, CA 95851-1300
All correspondence about claims, tracer claims, and appeals on claim denials or fee
reductions should be submitted to:
Medi-Cal/CHDP
Attn: Provider Relations
Correspondence Specialist
PO. Box 15300
Sacramento, CA 95851-1300
Providers may call the local CHDP program, or they may call EDS between 8 a.m. and
5 p.m. Monday through Friday when they have questions about a specific claim. The
telephone number for EDS is (916) 636-1000.
ALL QUESTIONS PERTAINING TO PROGRAM POLICY MUST BE DIRECTED TO THE
LOCAL CHDP PROGRAM.
OVERVIEW 502
Claims submitted by providers for payment pass through several edits, manual and
computer, which check for accuracy and the completion of required information on the
claim. These edits are:
1. The Manual pre-edit.
2. The "Critical" edit.
3. The "Fee-Adjustment” edit.
4. The "History" and "Extended Visit" edits.
Date 11/90
cp PROVIDER MANUAL @
PROCESSING OF CLAIMS
MANUAL PRE-EDIT
Overview
Claims are manually reviewed to assure that the following information is completed.
1. Patient's name (first and last).
2. Date of patient's next appointment. (For children over two years of age, enter a
month and year).
Provider's number, name, and address.
Provider or provider designee's original signature.
"Patient Eligibility” Section.
a. Ifbox 1 is marked in the "Patient Eligibility Section"
e the patient's two digit county code is entered in box labeled "County”;
the patient's two digit aid code is entered in box labeled "Aid" ; and
the patient's "County Identification Number” or "Social Security Number”
and "Check Digit" is entered in box labeled "Identification Number". (If the
"Social Security Number" and "Check Digit" are used, there will be four
blank digits at the end of the box.)
If box 2 is marked, a DHS 4073 eligibility form, completed and signed by the
parent/guardian/patient, is attached to the claim. EXCEPTION: A Head
Start/State Preschool PM 160 does not require a DHS 4073.
If any of the above information is missing or incorrect, the claim is returned to the
provider with a letter indicating the reasons for rejection. See Appendix, page C-9.
The provider should correct or enter any missing information and resubmit the claim.
Claims passing the Manual Edit are assigned a "Claim Control Number (CCN)" and
routed for key entry.
Date 11/90
® CHDP PROVIDER maar
PROCESSING OF CLAIMS
CRITICAL EDIT
Overview
After key entry of the claim and DHS 4073 data, the computer "Critical Edit" checks
that:
1. All necessary data is correct and has been entered (see PM 160 Instructions).
2. The child is eligible for CHDP program reimbursable services.
CLAIMS THAT "PASS" THE "CRITICAL EDIT" PROCEED TO THE "FEE ADJUSTMENT
EDIT".
CLAIMS THAT DO NOT "PASS" THE "CRITICAL EDIT" EITHER HAVE A "PROVIDER
CORRECTION REQUEST" ISSUED OR ARE DENIED.
Issuance of Provider Correction Request (PCR) 504.b
When data is missing or incorrect, a PCR which lists the problem(s) is generated and sent
to the provider. For example:
1. The patient's name on the claim does not match the name on the "Proof of Eligibility”
(POE) label.
"Date of Service" is missing.
"Date of Service" precedes "Date of Birth".
4. No assessment outcome is entered for tests required for that age child.
5. Answers to tobacco use questions are not documented.
See the Appendix, pages B-1 through B-6 for a list of all PCR messages, a sample PCR, a
key to its content, and a completed PCR.
Provider Action on PCRs 504.c
Providers must correct or complete the missing information and sign and resubmit the
PCR within the time-frame indicated {n the document.
Claim Denials Issued After PCRs B04.d
If the PCR is not returned within the time-frame indicated on the PCR, or the
information on the returned PCR does not allow the claim to pass the Critical Edit, the
claim is automatically denied, and a "Denial Notice" is issued and sent to the provider.
See the Appendix, page C-1 through C-5, for a list of aH the Denial Messages and a copy
of the "Notice of Claim Denial" issued from the "Critical Edit".
Date 1 1/90
d@oP PROVIDER MANUAKD !
Chapter
PROCESSING OF CLAIMS 500
Section
Denial of Claims Without Issuance of a Provider Correction Request 504.e
A "Notice of Claim Denial” will be issued without a PCR having been generated when the
data indicates the patient is not eligible for reimbursable services or fees for individual
procedures were not entered. For example:
1. The state file indicates the patient is not eligible for Medi-Cal on the Date of Service
and no Proof of Eligibility (POE) label or copy of a Medi-Cal card for the month of
service accompanies the claim.
2. The patient is not age eligible for CHDP reimbursable services.
3. The family income listed on the DHS 4073 is too high for the family size.
4. The Medi-Cal card or the DHS 4073 indicates the person is enrolled in a Health Plan
that covers Preventive Health services. See Appendix, pages E-14 through E-16 for a
list of health plan codes.
5. No fees were entered for individual procedures.
Process for Provider to appeal the "Notice of Claim Denial’ issued from the "Critical Edit" 504.f
To appeal the "Notice of Claim Denial" issued from the "Critical Edit", the provider must:
1. Complete and sigh a new PM 160 with all the necessary corrections and write the word
"Appeal" in the "Comments/Problems" section. Submittal of a new DHS 4073 is required if
the claim was denied because of incorrect or missing information on the original DHS 4073.
Submittal of a copy of the original DHS 4073 with all other appeals will expedite processing.
2. On the "Notice of Claim Denial,” note the reason(s) for appealing the denial and sign and
attach the "Notice of Claim Denial” to the new PM 160.
3. Malilto:
Medi-Cal/CHDP
Attn: Provider Relations
Correspondence Analyst
PO. Box 15300
Sacramento, CA 95851-1300
Date 11/90 Page 500.4
®
CHDP PROVIDER mara
Chapter
PROCESSING OF CLAIMS 500
Section
FEE ADJUSTMENT EDIT 505
Overview
505.2
The computer "Fee Adjustment Edit" checks for:
1. Fees billed above the maximum rate.
2. Calculation errors.
3. Fees entered for tests marked as not given.
4. Any inappropriate billing, e.g., billing for a pap smear on a male patient.
The computer makes needed adjustments to the fees entered on the claim. Fee
adjustment codes are shown on the Remittance Advice which accompanies all checks to
providers. Please see pages 500.11 through 500.14 for a description of the "Remittance
Advice" and a listing of all fee adjustment codes.
Process for Provider to Appeal Any Fee Adjustments 505.b
If in reviewing the "Remittance Advice", a provider feels fees were incorrectly adjusted,
reevaluation of any adjustment can be requested. For each claim for which an appeal is
made, submit:
1. A photocopy of the original claim.
2. A photocopy of the "Remittance Advice" showing the fee adjustment with the name of
the patient circled on the remittance advice.
3. A new signed PM 160 showing only the amount(s) the provider feels is still due. A
copy of a DHS 4073 is not required but will expedite processing.
4. A cover letter briefly explaining why the additional amount(s) is still owed, and
5. Mail to:
Medi-Cal/CHDP
Attn: Provider Relations
Correspondence Analyst
PO. Box 15300
Sacramento, CA 95851-1300
Date 11/90 Page 500.5
ci®Pp PROVIDER MANUAL®
Chapter
PROCESSING OF CLAIMS 500
Section
HISTORY EDIT/EXTENDED VISIT
508
Overview
5086.a
This final computer edit checks for duplicate services, services billed outside the
periodicity schedule, and services billed at the "Extended Visit" rate when the provider has
been reimbursed for services within the last two years for this patient. See the CHDP
Medical Guidelines and the section on Billing Restrictions.
Claims passing this edit are routed for payment.
Claims that do not pass this edit may be automatically denied or have fees reduced unless
adequate justification is written in the "Comments /Problems" section for an additional
visit or for billing the "Extended Visit" fee.
HISTORY EDIT 507
Duplicate Services 507.a
Duplicate services or "Tracer Claims" are automatically denied by the computer when the
file indicates these services have already been paid. A "Denial Letter for Duplicate
Services" is issued to the provider. See the Appendix, page C-6 for a copy of this letter.
Services Outside Periodicity Schedule 507.b
When claims are received for services provided more frequently than the periodicity
schedule indicates, and:
1. NO COMMENTS are entered in the "Comments/ Problems" section, and
a. If all services are outside the periodicity schedule, the claim is
automatically denied and a "History Edit Denial Letter” is issued. See the
Appendix, page C-7 for copy of letter.
b. If some but not all of the services are outside the periodicity schedule, the
services within the periodicity schedule are paid. The Fee Adjustment Code 53
appears on the Remittance Advice* and a "History Edit Partial Denial Letter" is
issued. See the Appendix, page C-8 for copy of letter.
92. COMMENTS ARE ENTERED in the "Comments/Problem” section, the claim is
reviewed to determine the appropriateness of the services:
a. If all services are deemed appropriate, the claim is routed for payment.
b. If some but not all of the services are deemed appropriate, a "Partial
History Edit Denial Letter” is issued informing the provider that some but not all
of the services have been denied.
c. If all services are denied, a "History Edit Denial Letter” is issued.
* See pages 500.11 through 500.14 for a description of the Remittance Advice and the fee adjustment codes.
Date 11/90 Page 500.6
CHDP PROVIDER MANUAL
Chapter
PROCESSING OF CLAIMS 800
Section
Process for Appeal of Claims Totally or Partially Denied by the History Edit 507.c
IF THE CLAIM IS PARTIALLY DENIED:
1. Complete and sign a new PM 160 entering only those services and fees that were
denied. A copy of the DHS 4073 is not required but will expedite processing.
2. Enter justification for the payment of these services in the "Comments /Problems”
section of the new PM 160.
3. Sign the "History Edit Partial Denial Letter" and attach to the back of the new
PM 160.
IF CLAIM IS TOTALLY DENIED AND PROVIDER FEELS ALL SERVICES SHOULD BE PAID:
1. Write justification for receiving payment for services on the "History Edit Denial
Letter”.
2. Sign the "History Edit Denial Letter".
A new PM 160 is not required.
Date 11/90 Page 500.7
@® or prOVIDER MANUA®
Chapter
PROCESSING OF CLAIMS 500
Section
EXTENDED VISIT EDIT 508
The same process is followed for claims when the "Extended Visit" fee is billed and the
provider was reimbursed for services within the last two years for that patient.
1. IF NO COMMENTS ARE ENTERED in the "Comments/Problems" section:
a. The fee for the History and physical Exam is reduced to the "Routine Visit" rate,
a "History Edit Partial Denial Letter” is issued, and
b. The Fee Adjustment code 37 is shown on the "Remittance Advice".
2. IF COMMENTS ARE ENTERED in the "Comments/Problems" section, the comments
are reviewed, and
a. The claim is paid at the "Extended Visit" rate if the reasons are deemed
appropriate, or
b. The fee is reduced to the "Routine Visit" rate if the reasons are deemed not
appropriate and a "History Edit Partial Denial Letter” is issued.
Process for Appeal of Claims When Fee is Cut From "Extended Visit" to "Routine Visit" Rate 508.a
1. Camplete and sign a new PM 160 with the difference between the two fees entered in the fee
column on the "History and Physical" line. A copy of the DHS 4073 is not required but will
expedite processing,
2. Enter justification for payment of the "Extended Visit" rate in the "Comments/Problems"
section.
3. Sign and attach the "History Edit Partial Denial Letter" to the back of the new PM 160.
Mail all appeals to:
Medi-Cal/CHDP
Attn: Provider Relations
Correspondence Analyst
PO. Box 15300
Sacramento, CA 95851-1300
Date 11/90 Page 500.8
CHDP PROVIDER MANUAL
Chapter
PROCESSING OF CLAIMS 500
Section
SUMMARY OF PROCESS FOR APPEALING PARTIAL OR COMPLETE DENIAL 509
OF CLAIMS
1. To appeal claims that are denied from the Critical Edit, (see pages 500.3 through
500.4) the provider must:
a. Complete and sign a new PM 160 with all the necessary corrections and write the
word "Appeal" in the "Camments/Problems" section. Submittal of a new DHS 4073 is
required ff the claim was denied because of incorrect or missing information on the
original DHS 4073. Submittal of a copy of the original DHS 4073 with all other
appeals will expedite processing.
b. On the "Notice of Claim Denial" note the reason(s) for appealing the denial and sign
and attach to the new PM 160.
2. To appeal a fee adjustment made to a claim, (see page 500.4) the provider must submit:
a. A photocopy of the orignal claim.
b. A photocopy of the "Remittance Advice" showing the fee adjustment with the name of
the patient circled on the remittance advice.
c. Anew signed PM 160 showing only the amount(s) the provider feels is still due. A copy
of a DHS 4073 is not required but will expedite processing.
d. A cover letter briefly explaining why the additional amount(s) is still owed.
3. To apeal claims totally or partially denied by the History Edit (See page 500.7).
a. If the claim is partially denied, the provider must:
e Complete and sign a new PM 160 entering only the services and fees that
were denied. A copy of the DHS 4073 is not required but will expedite
processing.
e Enter justification for payment of services in "Comments/Problems” section
of the new PM 160.
e Sign and attach the "History Edit Partial Denial Letter" to the back of the
new PM 160.
Date 11/90 Page 500.9
d@DP PROVIDER MANUAI{
Chapter
PROCESSING OF CLAIMS 500
Section
SUMMARY OF PROCESS FOR APPEALING PARTIAL OR COMPLETE DENIAL 509
OF CLAIMS (Cont.)
b. If the claim is totally denied, the provider must:
e Write a justification for receiving payment for services on the "History Edit
Denial Letter”.
e Sign the "History Edit Denial Letter”.
A new PM 160 is not required.
4. To appeal claims when the fee is cut from the "Extended Visit" to "Routine Visit" rate,
the provider must:
a. Complete and sign a new PM 160 with the difference between the two fees
entered in the fee column on the "History and Physical" line. A copy of the DHS
4073 is not required but will expedite processing.
b. Enter justification for payment of the "Extended Visit" rate in the
"Comments/Problems” section.
c. Sign and attach the "History Edit Partial Denial Letter" to the back of the new
PM 160.
ALL APPEALS MUST BE MAILED TO:
Medi-Cal/CHDP
Attn: Provider Relations
Correspondence Analyst
PO. Box 15300
Sacramento, CA 95851-1300
If it is determined that the appeals are valid the claims will be processed.
Providers will be notified if it is determined that the claims cannot be paid.*
* See Appendix for appeal process.
Date 11/90 Page 500.10
CHDP PROVIDER MANUAL
Chapter
PROCESSING OF CLAIMS 500
Section
REMITTANCE ADVICE 510
A "Remittance Advice" document is attached to each reimbursement check for CHDP
services. It is recommended that a copy of the check and "Remittance Advice" is made
and the "Remittance Advice" maintained at least until any issues about the claims have
been resolved.
The Remittance Advice includes the following information:
1. An indication that the check is for CHDP program services.
2. The name and address of the payee.
3. The check number and schedule number.
4. A subcenter, region, or district if the payee is a county treasurer in a county which is
divided into geographic areas.
5. Patient's name for which services are being paid.
6. Patient's County identification number or social security number if the patient is a
Medi-Cal patient. Otherwise, the second column is blank.
7. The claim control number (CCN) assigned by EDS to the claim which providers
should reference if an inquiry is necessary.
8. The date of service (DOS) indicating the date of service on the claim.
9. The amount paid for each claim.
10. Any fee adjustment (ADJ) code(s) which indicates any payment adjustments that
were made to the claim.
Date 11/90 Page 500.11
CHDP PROVIDER MANUAL
Chapter
PROCESSING OF CLAIMS 500
ADJUSTMENT CODES
10—Calculation Error:
20—Above Maximum Rate:
37—History/Physical Billed as an
Extended Visit:
40—Billed for Test Not Given:
45—Billed for Information-only Claim
50—Test Inappropriate at This Age:
Date 11/90
Section
510
EXPLANATION
This means that the sum of the individual
billed amounts did not equal the total
billed amount. The total billed amount has
been adjusted to equal the sum of the
individual fees.
This means that one or more individual fees
exceeded the maximum allowable rate for the
particular procedure. One or more individual
fees have been adjusted downward to the
maximum allowable rate.
This means that a history and physical was
billed as an extended visit before the allowable
two-year interval. No comments were entered
on the claim so the History and Physical fee
was cut back to the routine fee.
This means that one or more procedures were
listed as being "refused, contraindicated, or not
needed", yet a fee was listed for the procedure.
The fee has been deleted for that procedure.
This means that the eligibility box on the claim
was marked for information only, but fees are
present, so all the fees have been adjusted to
Zero.
Certain procedures are not usually appropriate
for children at certain ages. These include (1)
vision or audio tests on children under 3 years
of age; (2) gonorrhea cultures on children
under 9 years of age; and (3) PKU testing on
children over 6 months of age. This code
indicates that the fee for one of these
procedures has been deleted because the
child's age was inappropriate for the particular
procedure. Providers have the option of
entering an explanation of why the test
was given in the "Comments/Problems”
section. CHDP will pay with a valid
reason.
Page 500.12
® ior PROVIDER man@hL
Chapter
PROCESSING OF CLAIMS 500
Section
510
ADJUSTMENT CODES EXPLANATION
51—Inappropriate Billing for Urine Two procedures for testing urine are allowable:
Dipstick: The urine dipstick test and the urinalysis.
Both procedures are not allowable on the same
claim. This code means that a fee for the urine
dipstick has been deleted in favor of the fee for
the urinalysis.
53—One or More Assessments Exceeded This code means that one or more services on
the Frequency Rate: the claim exceeded the frequency rate specified
on the "CHDP Periodic Appointment Schedule”
and no comments were entered on the claim.
A denial or partial denial letter will also have
been sent to the provider.
55—Billing Inappropriate by School District This code applies to school district
Provider for School-Age Child: providers only. School districts have a long
standing statutory requirement to provide
vision and hearing tests to all children. This
code means that a fee for vision and/or
hearing has been deleted because the patient
was school age.
60—Immunization Assessed as Not Given: This means that a fee was listed for an
immunization (polio, DPT/Td, MMR, measles,
mumps, or rubella) but the provider indicated
that the immunization was not administered.
The fee has been deleted for the immunization
assessed as not given.
61-Rationale for Single Dose of Measles, This means that a single dose of the Measles,
Mumps, and/or Rubella not given: Mumps, or Rubella vaccine was given but a
rationale supporting the need for a single dose
was not given and so the fee was reduced to
Zero.
65—History/Physical Fee Disallowed on The fee for a History and Physical exam may
Partial Screen: only be billed on a complete screen. This code
means that a fee was charged for the History
and physical exam but the provider indicated
that the screen was a partial screen. The fee
for the history and physical has been deleted.
Date 11/90 Page 500.13
ci ®p PROVIDER MANUAL ®
Chapter
PROCESSING OF CLAIMS 500
Section
510
ADJUSTMENT CODES EXPLANATION
67—Claim Adjusted for Share of Cost: The MC177 has been checked to determine if
any of the procedures given by this provider to
this child on this date of service have been
used to meet the family's share of cost. The
procedures used to meet the share of cost have
been adjusted to reflect the amount remaining
due to the provider. (See Share of Cost
Section.)
68—Payment on Claim Reduced Due to When providers do not reimburse an
Automated Recoupment Process: overpayment that has been requested by EDS,
an automated recoupment process will be
done. A maximum of 90% of a single claim will
be reduced.
Date 11/90
Page 500.14
CHDP PROVIDER MANUAL
Chapter
PROCESSING OF CLAIMS 500
Section
REQUESTING A BALANCE DUE PAYMENT
511
When the provider wishes to appeal the amount reimbursed for a CHDP claim, the
provider should request a second evaluation of the unpaid balance by submitting:
1. A photocopy of the original claims(s).
2. A photocopy of the remittance advice associated with the claim with the name of the
patient circled.
3. a new signed PM 160 with the amount the provider feels is still owed and the
comment "Balance Due" written in the "Comments/Problems” section.
4. A cover letter that briefly explains why the provider believes the additional amount is
owed. If the amount is owed for an Extended Visit, justification for the Extended
Visit must be given.
If it is determined that the appeal is valid, the claim will be processed for payment.
If it is determined that the "Balance Due" claim should not be paid, the claim package
with a cover letter explaining why payment cannot be made will be returned to the
provider.
TRACING CLAIMS
512
If after a reasonable period of time (90 days), a provider's claim(s) has not been paid, has
not been denied, or has not been returned for corrections, the provider should request a
tracer on the claim(s) by submitting the following:
1. The name and telephone number of a contact person at the provider's office.
2. A new signed original PM 160 (no photocopies will be accepted) with the same
information as the original claim. Write "TRACER" in the "Comments/Problems”
section.
3. If the patient is not on Medi-Cal, an original or photocopy of the DHS 4073 eligibility
form stapled to the PM 160.
The CHDP Claims Processing Unit will not accept a tracer that is received more
than twelve (12) months from the date of service.
If it is determined that the claim has not been paid, it will be processed for payment.
If the claim is currently suspended in the system or has previously been paid or denied,
the provider will be notified of its status.
Date 11/90
Page 500.15
cn PROVIDER MANUAL 2
Chapter
PROCESSING CLAIMS 500
Section
RETROACTIVE PAYMENT FOR VACCINE 513
When vaccine fees are increased retroactively, the provider will be automatically
reimbursed for any fee differences in the vaccines given during that period.
The letter notifying the provider of the fee increase will also indicate the time period for
which the automatic reimbursements apply.
PROVIDER RETURNING OVERPAYMENTS
514
A provider who is overpaid for a claim submitted to the CHDP Program is responsible for
returning the amount of the overpayment to the Department of Health Services by
sending:
1. A photocopy of the "Remittance Advice" with the name of the patient circled for whom
the overpayment is being returned, and
2. A check made out to the State of California for the amount of the overpayment to:
Department of Health Services
Accounting/Cashiers
714 P Street, Room 1092
Sacramento, CA 95814
If the Department of Health Services or EDS determines that a provider has been
overpaid, EDS will request in writing the repayment of these funds.
If the provider does not return the funds within sixty (60) days, the amount owed the
State will be deducted from current claims and the Fee Adjustment Code 68 will appear
on the Remittance Advice. A maximum of ninety (90) percent of a claim would be reduced
on any single claim.
Date 11/90
Page 500.16
Qn PROVIDER MANSL
Chapter
PROCESSING OF CLAIMS 500
Section
REQUESTING VERIFICATION OF PAYMENT OR A REPLACEMENT CHECK 515
1. When a provider has gone through the process of submitting a "Tracer" for an unpaid
claim and has no record of payment, but receives notification from the Claims
Processing Unit that the claim has already been processed under the prior claim
number, the provider may send a written request to the CHDP Correspondence Unit
for verification of payment. The CHDP Correspondence Unit will send a written
response to the provider stating the schedule number, check number, and issue date
for payment of the claim in question.
2 When a check issued to a provider has been lost, stolen, or destroyed the provider
should submit a written notification providing the CHDP Correspondence Unit with
all the known details.
a. A CHDP Correspondence Specialist will trace the check by submitting a STD
435 form to the State Controller's Office requesting copies of the check (front
and back).
b. If the check is outstanding (HAS NOT BEEN CASHED) The CHDP
Correspondence Specialist will send the STD 435 to the provider. The provider
will then complete the middle section of the form and return it to:
State Controller's Office
Division of Disbursements
PO. Box 942850
Sacramento, CA 94250-5871
c. If the check HAS BEEN CASHED, the CHDP Correspondence Specialist will
send the provider the front and back copy of the check to verify that the check
had been issued to the provider.
d. If the check was cashed by someone other than the provider or authorized
representative, the provider should contact the Fraud Unit/Controller's Office at
(916) 323-5163.
ALLOW FOUR TO SIX WEEKS TO RECEIVE A DUPLICATE CHECK
Date 11/90 Page 500.17
APPENDIX A
SAMPLE OF FORMS
State of Cailfornia—tHeaith and Welfare Agency : Department of Health Services
CONSENT FORM
California Child Health & Disability Prevention Program
| hereby give my consent for {NAME OF PATIENT)
to receive the health screening tests and immunizations recommended by the CHDP Program. | hereby authorize
release of information conceming the results of these screening tests to CHDP Program personnel. | also authorize
release of the information to the locations checked below. | understand that information provided to CHDP Program
personnel will be strictly confidential and will be used only to make the provision of health services easier and to
permit statistical reporting on the results of screening.
{Check box)
a School
NAME
ADDRESS
a Health Care Provider RE
ADDRESS
O Other
NAME
ADDRESS
SIGNATURE OF PARENT, GUARDIAN, OR EMANCIPATED MINOR
DATE
NAME OF PARENT, GUARDIAN, OR EMANCIPATED MINOR
Screening Provider: This form signed by parent, guardian, or emancipated minor must be retained in patient's file.
PM 211 (Bilingual) (5/80)
State of Callfornia—Health and Welfare { i » Department of Health Services
CONSENTIMIENTO
Programa en California Para la Salud y Prevencion
de Incapacidades en Ninos (CHDP)
Por este medio doy mi permiso para que
Nombre del paciente
reciba un examén de salud é inmunizaciones recomendadas por CHDP. Por este medio doy mi authorizacién para dar
informacion tocante a los resultados del examén al personal de CHDP. También autorizo dar informacién a los
suguientes lugares con contrasefia(s) abajo. Yo entiendo que la informacién dada al personal de CHDP se mantendrd
estrictaments confidencial y se usard solamente para facilitar la provision de servicios de salud, y permitir la coleccion
de estadisticas tocantes a los resultados de estos examenes.
O Escuela
Nombre
Direccibn
£ Proveedor de
servicios de salud
Nombre
Direccién
a Otro
Nombre
Direccibn
Firma del pariente, acudiente, 0 menor de edad emancipado. Fecha
Nombre del pariente, acudiente, o menor de edad emancipado.
Screening Provider: This form signed by parent, guardian, or emancipated minor must be retained in patient's file.
A-1.1
PM 211 (Blilngual) (5/80)
a
VUPATIENT NAME ((AST) @- RST) {INITIAL)
’ |
tL |
€ |
Al ,
$| BARTHDA TE I SEX (CMCLE| | PATIENT'S COUNTY OF RESIDENCE CODE | TELEPHONE NUMBER
E| moO DAY | YEAR i
i i oy FREES AiG BEL
| Ly td ]
‘ | RESPONSIBLE PERSON (NAME (STREET) (CITY) 27
“|
i
vear Doctor:
The above named patient received a CHDP check-up on
The following suspected condition(s) was identified as needing further evaluation:
No. 1.
DATE OF CHDP CHECK-UP
After you have seen and examined the patient, please note your findings below.
if appropriate consent has been obtained below, please return the white copy to
me and the pink copy to the following community CHDP program:
Thank you,
SIGNATURE OF CHDP CHECK-UP PROVIDER DATE
CONSENT: | have read the release of information disclosure on the reverse of Copy 4 and | hereby authorize release of information to:
BE
i
| | CHDP Program Personnel
' ‘
—_—,
Check-Up Provider
SIGNATURE OF RESPONSIBLE PERSON DATE
A. What was your diagnosis (I.C.D.A. terminology)
of SUSPECTED CONDITION NO. 1?
What was your diagnosis (I.C.D.A. terminology) of
SUSPECTED CONDITION NO. 2? |
|
|
|| What was your diagnosis (I.C.D.A. terminology) of
SUSPECTED CONDITION NO. 3?
1.C.D.A. CODE (Ophonal)
jofe 4 0
I.C.D.A. CODE (Optional)
ok Ta SY
1.C.D.A. CODE (Optional)
8
B. RESULT OF DIAGNOSIS: Check appropriate line.
ABNORMALITY NOT CONFIRMED
ABNORMALITY CONFIRMED:
No treatment indicated
Treatment indicated—given
Treatment indicated—eterred
Treatment indicated—not given or referred
REASON:
RESULT OF DIAGNOSIS: Check appropriate fine.
—— ABNORMALITY NOT CONFIRMED
ABNORMALITY CONFIRMED:
No treatment indicated
Treatment indicated—given
Treatment indicated—referred
REASON:
Treatment indicated—not given or referred
RESULT OF DIAGNOSIS: Check appropriate fine
— ABNORMALITY NOT CONFIRMED
ABNORMALITY CONFIRMED:
No treatment indicated
Treatment indicated—given
Treatment indicated—referred
Treatment indicated—not given or referred
REASON:
ATIENT EXAMINED BY
» DAY
MO. |
|
DATE EXAMINED
YEAR
DOCTOR'S TELEPHONE NUMBER:
CONFIDENTIAL REFERRAL/FOLLOW UP REPORT
STATE OF CALIFORNIA—CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
PM 161 (7-78) A-2
BS 989
state of Callfornia—Health and Weifare Agency
REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY
Department of Health Services
Chiid Health and Disability Prevention Program
TO PROTECT THE HEALTH OF CHILDREN, CALIFORNIA LAW REQUIRES A HEALTH EXAMINATION ON SCHOOL ENTRY. PLEASE HAVE THIS REPORT FILLED OUT
BY A HEALTH EXAMINER AND RETURN IT TO THE SCHOOL~-THE SCHOOL WILL KEEP AND MAINTAIN IT AS CONFIDENTIAL INFORMATION.
TO BE FILLED OUT BY PARENT OR GUARDIAN
* All tests and evaluations must be done after the child is 4% years of age.
PART |
Birthdate:
CHILD'S NAME Last First Middle Month Day Year
ADDRESS Street Clty Zip Code School
PART II
HEALTH EXAMINATION IMMUNIZATION RECORD
Date Each Dose Was Given
Required Tests and Evaluations® Check When Vaccine
Completed 1st 2nd 3rd 4th Sth
Health and Developmental History -— Polio (TOPV/IPV) (circle one)
Physical Examination | EEW / [ / / / / / L
Nutritional Assessment DPT/Td/DT (circle one)
| Vision Screening SE LL... .L Led F and |
Audiometric (hearing) Screening Mebsias" * Record only doses given on or after first birthday.
Blood Test (for anemia) [ L Note to Examiner: Please give the family acompleted, or updated,
Urine Test . yellow California Immunization Record or other personal
Tuberculin Test Rubella / / immunization record.
Other:
Note to School: Please record immunization dates on the blue
Mumps*® [7 California School Immunization Record (PM 286).
PART lil ADDITIONAL INFORMATION FROM HEALTH EXAMINER (Optional)
Fill out if parent or guardian has signed release of health information below.
RESULTS AND RECOMMENDATIONS
O Examination revealed no condition relevant to the school program,
O Conditions found in the examination or after further evaluation which are
of importance to schooling or physical activity are: (please explain)
Name, address, and telephone number of health examiner:
Signature of Health Examiner Date
RELEASE OF HEALTH INFORMATION
| give permission to share the additional results of this examination with the school as stated in Part Ill.
[J Please check the box if you do not want the health examiner to fill out Part II,
Signature of Parent or Guardian Date
If unable to get the examination done, call the Child Health and Disability Prevention Program in your local health department. If you do not want your child to have an examination,
you may sign the waiver (PM 1718) form obtained from your child's school.
ass a cS a
State of Callifornia—#Heaith and Welfare Agency
epariiimiy wi rieaith Services
Child Health and Disability Preventien Program
INFORME DEL EXAMEN DE LA SALUD PARA EL INGRESO A LA ESCUELA
PARA PROTEGER LA SALUD DE LOS NINOS, LA LEY DE CALIFORNIA EXIGE QUE ANTES DE INGRESAR A LA ESCUELA ELLOS TENGAN UN EXAMEN MEDICO DE
SU SALUD. POR FAVOR, PIDALE A QUIEN HA HECHO EL EXAMEN QUE LLENE ESTE INFORME Y LLEVELO A LA ESCUELA-ESTE INFORME SERA GUARDADO Y
MANTENIDO POR LA ESCUELA EN FORMA CONFIDENCIAL.
PARTE | PARA SER LLENADA POR EL PADRE/LA MADRE O EL GUARDIAN
on : Ay Fecha de Nacimiento:
NOMBRE DEL NIRO/DE LA NINA Apellido Primer Nombre Segundo Nombre Maes Dfa Afo
DIRECCION Calle Cludad Zona Postal Escuela
PARTE li
EXAMEN DE LA SALUD Fecha: inion RECORD DE LAS INMUNIZACIONES
Fecha en que Cada Dosis Fue Dads
Pruebas y Evaluaciones Requeridas*® indique Cuando Vacuna
se Completaron 1a. 2a. 3a. 4a. Ba. .
Historia de la Salud y su Desarrollo
Polio (TOPV/IPV) (marque una)
Examen Ff(sico il. } {= of / / Led L==1
Evasluacion de la Nutricion ;
. DPT/Td/DT (marque una)
Pruebas Visuales ; % 1.4 Ji / 4 L Ll. -1 Ji Ji
Pruebas con el Audibmetro (auditivas) Siramiitn * Récord de las dosis dadas s6lo en 0 después del primer
Anélisis de la Sangre (para anemia) P ’ 9 cumpleafos.
. Y Aviso al Examinsdor: Por f dé a la famiil
Anélisis de Orina Rubdola® com ae, o ala fecha, o Récord goad Mgr
Pr ee Fberculins / / cal ola a papel amarillo u otro récord de inmuniza-
Otra: p . Aviso a la Escuela: Pos favor pongan las fechas de las *
speras / / inmunizaciones en la pdgina azul del Récord de Inmuniza-
ciones de la Escuela en lifornia (PM 286).
*Todas las pruebas y evaluaciones deben ser hechas después que el/la nifio(a) tenga 4-1/4 afios de edad.
PARTE Ill INFORMACION ADICIONAL DEL EXAMINADOR DE LA SALUD
(Opcional)
Llene esta parte si el padre/la madre o el guardidn ha firmado més abajo el Nombre, direccién y teléfono del examinador:
consentimiento para divulgar el informe sobre la salud.
ww
RESULTADOS Y RECOMENDACIONES
0 El examen reveld que no hay condiciones que conciernen al programa
escolar.
0 Las condiciones encontradas en el examen o después dé una evaluacion
posterior importantes para la actividad escolar o fisica son: (por favor
explique)
Firma del Examinador de la Salud Fecha
PERMISO PARA DIVULGAR EL INFORME SOBRE LA SALUD
Doy permiso para compartir con la escuela los resultados adicionales de este examen como se indica en ls
Parte lil.
(J Por favor marque el casillero si Ud. no desea que el examinador llene la Parte 111.
Firma del Padre/de la Madre o Guardian Fecha
Si no puede obtener el examen lame al Programa de Salud para la Prevencién de Incapacidades en Nifios y Jévenes (Child Health and Disability Prevention Program) en su deps'tamen--
to local de salud. Si Ud. no desea que su nifio(a) tenga un examen, puede firmar la orden (PM 1718), formulario que consigue en la escuela donde va su nifio(a).
00 39008
APPENDIX B
PROVIDER CORRECTION REQUESTS
PROVIDER CORRECTION REQUEST (PCR) MESSAGES AND EXPLANATIONS
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE.
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
PRIOR PM 160 DATE REQUIRED
The partial screen box was marked so the date of the last CHDP
assessment is required.
PLEASE VERIFY BIRTHDATE
Verify patient's date of birth. Please provide correct information.
PLEASE VERIFY DATE OF SERVICE
Verify the date of service. Please provide correct information.
ONE OF THE TWO TB SCREENING ASSESSMENTS REQUIRED
The TB test type and/or assessment outcome is missing or incorrectly
marked on the claim. Please provide correct information.
MULTI-SHOT TYPE ASSESSMENT REQUIRED FOR AGE
The multi-shot type (MMR, MuR, MR) and/or assessment outcome is
missing or incorrectly marked on the claim. Please provide correct
information.
NO PATIENT VISIT CODE
The patient visit type is missing or incorrectly marked on the claim.
Please provide correct information.
HX AND PE ASSESSMENT OUTCOME REQUIRED
The history and physical assessment outcome is missing or incorrectly
marked on the claim. Please provide correct information.
DENTAL ASSESSMENT OUTCOME REQUIRED FOR AGE
The dental assessment outcome is missing or incorrectly marked on the
claim. Please provide correct information.
NUTRITIONAL ASSESSMENT OUTCOME REQUIRED
The nutritional assessment outcome is missing or incorrectly marked on
the claim. Please provide correct information.
VISION ASSESSMENT OUTC OME REQUIRED
The vision assessment outcome is missing or incorrectly marked on the
claim. Please provide correct information.
AUDIOMETRIC ASSESSMENT OUTCOME REQUIRED
The hearing assessment outcome is missing or incorrectly marked on
the claim. Please provide correct information.
HGB/HCT ASSESSMENT OUTCOME REQUIRED FOR AGE
The assessment outcome for hemoglobin or hematocrit is missing or
incorrectly marked on the claim. Please provide correct information.
ONE OF THE TWO URINE SCREENING ASSESSMENT REQUIRED
The urine dipstick or complete urinalysis outcome is missing or
incorrectly marked on the claim. Please provide correct information
B-1
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
POLIO ASSESSMENT REQUIRED FOR AGE
The polio assessment outcome is missing or incorrectly marked on the
claim. Please provide correct information.
DPT/TD ASSESSMENT REQUIRED FOR AGE
The DPT/TD assessment outcome is missing or incorrectly marked on
the claim. Please provide correct information.
OTHER SHOT 1 ASSESSMENT REQUIRED
OTHER SHOT 2 ASSESSMENT REQUIRED
OTHER SHOT 3 ASSESSMENT REQUIRED
The assessment outcome for the indicated other shot is missing or
incorrectly marked on the claim. Please provide correct information.
ASSESSMENT OUTCOME REQUIRED FOR 1ST OTHER TEST
ASSESSMENT OUTCOME REQUIRED FOR 2ND OTHER TEST
ASSESSMENT OUTCOME REQUIRED FOR 3RD OTHER TEST
The assessment outcome for the indicated other test is missing or
incorrectly marked on the claim. Please provide correct information.
FOLLOW UP CODE REQUIRED FOR HX AND PE
FOLLOW UP CODE REQUIRED FOR DENTAL
FOLLOW UP CODE REQUIRED FOR NUTRITIONAL
FOLLOW UP CODE REQUIRED FOR VISION
FOLLOW UP CODE REQUIRED FOR HEARING
FOLLOW UP CODE REQUIRED FOR HGB/HCT
FOLLOW UP CODE REQUIRED FOR URINE DIPSTICK
FOLLOW UP CODE REQUIRED FOR TB
FOLLOW UP CODE REQUIRED FOR 1ST OTHER TEST
FOLLOW UP CODE REQUIRED FOR 2ND OTHER TEST
FOLLOW UP CODE REQUIRED FOR 3RD OTHER TEST
FOLLOW UP CODE REQUIRED FOR ANTICIPATORY GUIDANCE/
HEALTH EDUCATION
FOLLOW UP CODE REQUIRED FOR DEVELOPMENTAL ASSESSMENT
The follow-up code for the indicated assessment/test has been
incorrectly marked. Please provide correct code (1,2,3.4,5,6); these
codes are listed on the claim form.
CAN'T PAY HX/PE WITH MARK IN COLUMN 2 (RCN)
The assessment for the history and physical was marked as refused,
contraindicated or not needed, yet there are no fees given for this
assessment. Please indicate correct assessment outcome and fees for
history and physical.
RECHECK DATE CANNOT BE SAME AS DATE OF SERVICE
The recheck date in the prior PM 160 date box is the same as the date of
service. Please provide the prior date of service that required a recheck.
VALID MEDI-CAL 1.D. REQUIRED
The Medi-Cal number provided is not valid. Please provide valid Medi-
Cal 1.D. or social security number for this patient.
B-2
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
CHILD'S OWN MEDI-CAL 1.D. IS REQUIRED, STATE REGULATIONS
ONLY ALLOW A NEWBORN TO USE MOTHER'S P.O.E. LABEL FOR THE
MONTH OF BIRTH AND THE MONTH AFTER
The Medi-Cal number provided is not for the patient and the date of
service is not for the month of birth or the month after birth. Please
provide the child's own Medi-Cal 1.D.
VERIFY SEX
The box indicating the sex of the patient has either not been marked or
the sex indicated on the claim does not match the sex indicated on the
Medi-Cal P.O.E. sticker. Please provide the correct information.
VERIFY PATIENT NAME WITH MEDI-CAL 1.D.
The name on the claim does not match exactly with the name on the
Medi-Cal P.O.E. sticker. Please provide correct information.
ASSESSMENT OUTCOME REQUIRED FOR HIB CV
The HIB CV assessment outcome is missing or incorrectly marked on the
claim.
ANTICIPATORY ASSESSMENT REQUIRED
The assessment outcome for anticipatory guidance/health education is
missing or incorrectly marked on the claim. Please provide correct
information.
TOBACCO RESPONSES MUST BE EITHER "Y"' OR "N".
Answers to tobacco questions are not documented on the claim.
State of California—Hezalth and Welfare Agency
Pete Wilson, Governor
Medi-Cal/CHDP
P. O. Bax 15300
Sacramento, CA 95851-1300
(916) 636-1000
PROVIDER CORRECTION REQUEST
May 26, 1990
1
JOHN SMITH, M.D. 2
1004 ANY STREET
SACRAMENTO, CA 95816
Dear CHDP Provider:
3
In order to process the following Screening/Billing Report (PM 160), we require the additional
information described below. Please enter this information in the space provided and return
this notice to us by 07-23-90, signed by you or your representative. Further processing of your
claim is dependent upon your prompt response to this request.
BE
tas bu osha hues dooce ch cart chat hushuasionfhdoston oudiegheduthatin stuf
Thank you for your participation in the Child Health and Disability Prevention program.
Claim Control No.: 04 9 012000190 2 4
PM 160 INFORMATION: 5
Provider Number: 00A123456
Patient Name: JULIE BROWN
Date of Birth: 02-27-70
Date of Service: 04-15-90
Total Fees: $55.15
"REQUIRED INFORMATION: ihe GARRATS Dahl RAL
Hx and Pe assessment outcome required.
0
A
PLEASE CORRECT OR COMPLETE: 7 State
Use 8
Only
7C
No New Known
Prob RCN Problem Problem
7A (1) (2) Code(s) Code(s)
1st 2nd 1st 2nd
Procedure: History and Physical i Ta Lot. ana Nd
7B
(06)
Hx/Pe Fee: $38.37 {oped od (28)
COMMENTS: 9
KEY TO CONTENT AND DESCRIPTION OF
COMPUTER-ENTERED ITEMS ON THE PROVIDER CORRECTION REQUEST
1. DATE OF NOTICE SENT
2. PROVIDER NAME AND ADDRESS
3. Date this document must be returned by the provider or a Denial Notice will be
automatically issued.
4. CLAIM CONTROL NUMBER: A number assigned by the Claims Processing Unit. (Use this
number to identify the claim when calling about a PCR Notice).
5. PM 160 INSTRUCTIONS: Identifying information. (Always check the birthdate and the
date of service for accuracy. If you note that the date of birth or the date of service are
incorrect, even though they are not shown as required information on the PCR, please
note the correct date(s) in the Comments section).
6. REQUIRED INFORMATION: Identifies the error or information needed.
7. PLEASE CORRECT OR COMPLETE:
7A. Lists items to be corrected or completed.
7B. Any monetary values appearing in this column are the same as those that appear on
the claim. A change needs to be coded only if you are adding or increasing an
amount.
7C. Provides spaces L_1__1 similar to the PM 160 in which the corrections must be
entered.*
8. STATE USE ONLY: Ignore the numbers in this column.
9. COMMENTS: Space is provided for comments.
10. SIGNATURE BLOCK: Original signature in ink is required.
THE NOTICE MUST BE SIGNED BEFORE IT IS RETURNED. A PCR WITHOUT AN ORIGINAL
SIGNATURE WILL NOT BE PROCESSED.
Submit to:
Medi-Cal/CHDP
Attn: Provider Relations
Correspondence Analyst
P. O. Box 15300
Sacramento, CA 95851-1300
*RCN means Refused, Contraindicated, or Not Needed.
State of Caltfornia—Health and Welfare Agency Pete Wilson, Governor
Medi-Cal/CHDP
P. O. Box 15300
Sacramento, CA 95851-1300
(916) 636-1000
PROVIDER CORRECTION REQUEST
May 26, 1990
JOHN SMITH, M.D.
1004 ANY STREET
SACRAMENTO, CA 95816
Dear CHDP Provider:
In order to process the following Screening/Billing Report (PM 160), we require the additional
information described below. Please enter this information in the space provided and return
this notice to us by 07-23-90, signed by you or your representative. Further processing of your
claim is dependent upon your prompt response to this request.
If you need assistance completing this request, contact your local CHDP program.
Thank you for your participation in the Child Health and Disability Prevention program.
Claim Control No.: 04 9 012000190 2
PM 160 INFORMATION:
Provider Number: 00A123456
Patient Name: JULIE BROWN
Date of Birth: 02-27-70
Date of Service: 04-15-90
Total Fees: $55.15
REQUIRED INFORMATION:
Hx and Pe assessment outcome required.
PLEASE CORRECT OR COMPLETE: State
Use
Only
No New Known
Prob RCN Problem Problem
(1) (2) Code(s) Code(s)
Ist 2nd 1st 2nd
Procedure: History and Physical LJ ee bia 4 9 dt totbaaod
(06)
Hx/Pe Fee: $38.37 {in $9 (28)
COMMENTS:
Signature of Provider or Rep.
B-6
APPENDIX C
CLAIM DENIAL MESSAGES
AND EXPLANATIONS
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
BILLED - OTHER TEST NOT GIVEN
One or more of the other tests were billed; however, the claim indicated
that the test was not given.
BLOOD ASSESSMENT REQUIRED FOR AGE
The HGB/HCT assessment outcome was not indicated on the claim.
Either box A (NO PROBLEM) or Box B (REFUSED, CONTRAINDICATED,
OR NOT NEEDED) must be checked; or the known or new problem boxes
should contain the appropriate follow-up code.
INDIVIDUAL FEES NOT GIVEN
The total billed amount was filled in; however, the fees for the individual
services were not itemized.
DATE: INVALID DAY FOR MONTH
The day of the month is not valid for either the date of service, the date of
birth, or the prior PM 160 date. An example would be the 32nd day of a
month or the 30th day of February.
DATE: INVALID MONTH
The month entered in either the date of service, date of birth, or the prior
PM 160 date is not a valid month. An example would be 13 entered for a
month.
DENTAL ASSESSMENT REQUIRED FOR AGE
The dental assessment outcome was not indicated on the claim. Either
Box A (NO PROBLEM) must be checked; or the known or new problem
boxes should contain the appropriate follow-up code.
DOB LATER THAN SERVICE DATE
The date of birth on the claim is one that is after the date of service.
DOS LATER THAN CURRENT DATE
The date of service on the claim is a future date in comparison with the
receipt date of the claim by EDS.
DPT/TD ASSESSMENT REQUIRED FOR AGE
The DPT/TD assessment outcome was not indicated on the claim. Either
Box A (GIVEN TODAY, NOW UP TO DATE), Box B (GIVEN TODAY, STILL
NOT UP TO DATE), Box C (NOT GIVEN, ALREADY UP TO DATE FOR
AGE), or Box D (REFUSED, CONTRAINDICATED, OR NOT NEEDED)
must be checked.
DUPLICATE TEST
The other test portion of the claim contains two entries for the same test.
HX/PE ASSESSMENT REQUIRED
The history and physical exam assessment outcome was not indicated on
the claim. Either Bax A (NO PROBLEM), must be checked: or the known
or new problem boxes should contain the appropriate follow-up code.
C-1
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
INVALID AID CODE
The third and fourth digits of the Medi-Cal number are not valid. It is
advisable to review the Medi-Cal number on the claim against the number
on the Medi-Cal card.
INVALID MEDI-CAL NUMBER
The Medi-Cal number entered on the claim is invalid. Verify the number
entered on the claim with the number on the patient's Medi-Cal card.
Also verify that the name, birth year, and month of eligibility on the Medi-
Cal P.O.E. sticker is for the patient.
INVALID PATIENT NAME
The patient name on the eligibility file does not match that used in the
patient name field on the claim form.
NO PATIENT VISIT CODE
The patient visit code box on the claim form was not checked or both
boxes were checked. Either the "NEW PATIENT OR EXTENDED VISIT"
box or "ROUTINE VISIT BOX" must be checked.
MMR ASSESSMENT REQUIRED FOR AGE
The MMR Assessment was not indicated on the claim. Either Box A
(GIVEN TODAY, NOW UP TO DATE FOR AGE), OR BOX C (NOT GIVEN,
ALREADY UP TO DATE FOR AGE), OR Box D (REFUSED,
CONTRAINDICATED, OR NOT NEEDED) must be checked.
NO FEES/NOT INFO-ONLY CLAIM
The claim form had no fees entered, therefore, there was nothing to be
paid. The eligibility box checked was not info-only.
NON-NUMERIC BIRTHDATE
The birthdate is something other than numbers. It may be blanks or
letters.
NON-NUMERIC DATE OF SERVICE
The date of service is something other than numbers. It may be blanks or
letters.
NUTRITION ASSESSMENT REQUIRED
The nutrition assessment outcome was not indicated on the claim. Either
Box A (NO PROBLEM) or Box B (REFUSED, CONTRAINDICATED, OR NOT
NEEDED) must be checked; or the known or new problem boxes should
contain the appropriate follow-up code.
PATIENT AGE 21 OR OVER
The patient's age is 21 or older, indicating that he/she is no longer eligible
for CHDP exams.
PATIENT LESS THAN 2 DAYS OLD
The child is younger than routinely allowed for CHDP reimbursement, and
no reason for the visit was given.
C-2
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
POLIO ASSESSMENT REQUIRED FOR AGE
The polio assessment outcome was not indicated on the claim. Either Box
A (GIVEN TODAY, NOW UP TO DATE FOR AGE), Box B (GIVEN TODAY,
STILL NOT UP TO DATE FOR AGE), Box C (NOT GIVEN TODAY, ALREADY
UP TO DATE FOR AGE), or Box D (REFUSED, CONTRAINDICATED. OR
NOT NEEDED) must be checked.
PRIOR DATE CANNOT MATCH DOS
The prior PM 160 date filled in on the claim is the same as the date of
service.
PRIOR PM 160 DATE NEEDED
The claim was submitted as a partial screen without a prior PM 160 date.
PROVIDER NOT ELIGIBLE ON DOS
The provider is not classified as a CHDP provider on the date of service.
Any claims processed before the provider's date of activation or after the
provider's date of deactivation will be denied.
PT ENROLLED IN PHP OR HMO
The patient is enrolled in a prepaid health plan or a health maintenance
organization and must receive services from this PHP or HMO.
TB ASSESSMENT REQUIRED FOR AGE
The TB assessment outcome was not indicated on the claim. Either Box A
(NO PROBLEM), or Box B (REFUSED, CONTRAINDICATED, OR NOT
NEEDED), must be checked; or the known or new problem boxes should
contain the appropriate follow-up code.
TB TEST TYPE REQUIRED
The claim did not indicate the type of TB test given - either multipuncture
or Mantoux.
TEST TYPE MISSING
An assessment box for one of the other tests was checked, but the test code
was omitted.
WRONG SEX FOR PAP SMEAR
A pap smear was indicated as an other test; however, the sex box checked
indicated that the patient is a male.
ELIGIBILITY #1 OR #2 MUST BE YES
The question on DHS 4073 - Less than 19 years of age? - must be answered
yes.
ON MEDI-CAL NEED ID NUMBER
According to question on DHS 4073 - On Medi-Cal Now? - the answer Yes;
therefore, a Medi-Cal ID number or social security number is required.
ENROLLED IN PREPAID HEALTH PLAN
According to question on DHS 4073 - In a Prepaid Health Plan? - the
answer is Yes; therefore, the patient must receive services from the PHP or
HMO.
INELIGIBLE BASED ON INCOME
Income is greater than is allowed to be eligible for state funded services.
C-3
MESSAGE.
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
MESSAGE:
EXPLANATION:
NUMBER IN FAMILY MUST BE > 0
In regards to question on DHS 4073 - How Many People Are In Your
Family? - the answer given was zero, must have a number greater than
zero as the answer.
FAMILY INCOME MUST BE GIVEN
In reference to question on DHS 4073 - How Much Money Does Your
Family Make Before Taxes? - answer given was blank, must have a money
amount or a zero.
INCOME INDICATOR MUST BE M ORY
Income not designated as a monthly or yearly amount.
ELIG #1 - #4 MUSTBE YORN
Questions on eligibility form DHS 4073 were not answered or both Yes
and No were filled in for the answers.
TEST NOT VALID FOR DOS
The DOS claim is before the date of service the test became reimbursable
for CHDP providers. (On fee adjustment notices.)
TEST NOT VALID FOR MALE
The other test indicated is for females only: on the claim the sex box
indicates the patient is a male. (On fee adjustment notices.)
INCOMPLETE TOBACCO RESPONSES
Responses to tobacco questions are not documented on the claim.
DOS <EFF DTE FOR OBRA/IRCA
CHDP services were provided prior to the date that reimbursement
became effective for this aid code. (See Appendix, pages E-1 and E-2))
OBRA/IRCA AGE 18 OR OVER
Patient is age eighteen (18) or over, and CHDP services, therefore, are not
reimbursable with this aid code. (See Appendix, pages E-1 and E-2.)
OBRA/IRCA AID CODE
The CHDP services given are not reimbursable with this patient's aid
code. (See Appendix, pages E-1 and E-2))
REPORT NO.:
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH SERVICES
CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
NOTICE OF CLAIM DENIAL
THE FOLLOWING CONFIDENTIAL SCREENING/BILLING REPORT (PM 160) HAS BEEN
DENIED PAYMENT:
PM 160 INFORMATION
CLAIM I.D.:
PROVIDER NUMBER:
PATIENT NAME:
DATE OF BIRTH:
DATE OF SERVICE:
TOTAL FEES:
DENIAL REASON(S):
DENIAL NOTICE FROM CRITICAL EDIT
IF YOU HAVE QUESTIONS REGARDING THIS DENIAL OR WISH TO APPEAL THIS
ADJUDICATION PLEASE CONTACT
MEDI-CAL/CHDP
P. O. Box 15300
Sacramento, CA 95851-1300
(916) 636-1000
C-5
State of Caltfornie—iHealth and Welfare Agency Pete Wilson, Governor
MEDI-CAL/CHDP
P. O. BOX 15300
SACRAMENTO, CA 95851-1300
DATE: PRIOR
CLAIM NUMBER:
CLAIM NUMBER:
PATIENT:
DATE OF
BIRTH:
DATE OF
SERVICE:
PROVIDER NUMBER:
DEAR CHDP PROVIDER:
A TRACER OR DUPLICATE CLAIM WAS PROCESSED THROUGH THE CHDP HISTORY EDIT.
WE FIND THE ORIGINAL CLAIM PROCESSED UNDER THE PRIOR CLAIM CONTROL NUMBER
REFERENCED ABOVE. PLEASE REVIEW YOUR REMITTANCE ADVICES FOR PAYMENT
INFORMATION.
QUESTIONS SHOULD BE DIRECTED TO YOUR LOCAL CHDP PROGRAM.
DENIAL LETTER FOR DUPLICATE SERVICES
C-6
State of California—Health and Welfare Agency Pete Wilson, Governor
MEDI-CAL/CHDP
P. O. BOX 15300
SACRAMENTO, CA 95851-1300
DATE:
CLAIM NUMBER:
PRIOR
CLAIM NUMBER:
PATIENT:
DATE OF
BIRTH:
PROVIDER NUMBER: DATE OF
SERVICE:
PRIOR DATE
OF SERVICE:
DEAR CHDP PROVIDER:
PAYMENT OF THE CLAIM IDENTIFIED ABOVE HAS BEEN DENIED. THE CLAIM WAS
SUSPENDED BY THE CHDP HISTORY EDIT DUE TO THE FACT THAT THE SERVICE(S)
BILLED EXCEEDED THE FREQUENCY RATE SPECIFIED BY THE CHDP PERIODIC
APPOINTMENT SCHEDULE AND A REVIEW OF THE COMMENTS SECTION DISCLOSED NO
ACCEPTABLE REASON FOR AN EXTRA ASSESSMENT.
IF YOU WISH TO APPEAL THIS DECISION PLEASE DIRECT YOUR APPEAL, IN WRITING, TO:
BRANCH CHIEF
CHILD HEALTH AND DISABILITY
PREVENTION PROGRAM
714 P STREET, ROOM 708
SACRAMENTO, CA 95814
PLEASE REFER TO CHDP PROVIDER INFORMATION NOTICE #86-11 WHICH OUTLINES THE
APPEAL PROCESS. IF YOU HAVE ANY FURTHER QUESTIONS ABOUT THIS PROCEDURE,
YOU MAY CONTACT YOUR LOCAL CHDP PROGRAM.
HISTORY EDIT DENIAL LETTER
State of Caltfornia—Health and Welfare Agency Pete Wilson, Governor
MEDI-CAL/CHDP
P. O. BOX 15300
SACRAMENTO, CA 95851-1300
CLAIM NUMBER:
DATE.
PRIOR
CLAIM NUMBER:
PATIENT:
DATE OF
BIRTH:
PROVIDER NUMBER: DATE OF
SERVICE:
PRIOR DATE
OF SERVICES:
DEAR CHDP PROVIDER:
PAYMENT OF THE CLAIM HAS BEEN PARTIALLY DENIED. THE CLAIM WAS SUSPENDED BY
THE CHDP HISTORY EDIT BECAUSE ONE OR MORE OF THE SERVICES BILLED EXCEEDED
THE FREQUENCY RATE SPECIFIED BY THE CHDP PERIODIC APPOINTMENT SCHEDULE
AND A REVIEW OF THE COMMENTS SECTION DISCLOSED NO ACCEPTABLE REASON FOR
THESE SERVICES.
IF YOU WISH TO APPEAL THIS DECISION PLEASE DIRECT YOUR APPEAL, IN WRITING, TO:
BRANCH CHIEF
CHILD HEALTH AND DISABILITY
PREVENTION PROGRAM
714 P STREET, ROOM 708
SACRAMENTO, CA 95814
PLEASE REFER TO CHDP PROVIDER INFORMATION NOTICE #86-11 WHICH OUTLINES THE
APPEAL PROCESS. IF YOU HAVE ANY FURTHER QUESTIONS ABOUT THIS PROCEDURE,
YOU MAY CONTACT YOUR LOCAL CHDP PROGRAM.
ALL ALLOWABLE TESTS AND/OR IMMUNIZATIONS BILLED ON THIS CLAIM HAVE BEEN
PROCESSED FOR PAYMENT.
HISTORY EDIT PARTIAL DENIAL LETTER
C-8
STATE Of CALIFORNIA—MEALTH AND WELFARE AGENCY GEORGE DEVKMENIAN, Governor
DEPARTMENT OF HEALTH SERVICES
714/744 P STREET
SACRAMENTO, CA 95814
Date:
Dear CHDP Provider:
The attached PM 160(s) cannot be processed for payment for the reason(s) indicated below. Please note that,
when making corrections or additions to a PM 160 or a DHS 4073, the person doing so must initial each change.
There may be other erors, sO please review your claim carefully before returning it to the Claims Processing
Contractor. Return corrected forms to:
Medi-Cal/CHDP
Fiscal intermediary
PO. Box 15300
Sacramento, CA 95851-1300
Please contact your local CHDP program if necessary for instructions or additional information regarding your
claim(s). Thank you.
I. PM 160 Confidential Screening/Bllling Report
A. Provider of Service
Information section
(1) Number omitted, incomplete or illegible
(2) Name and/or address omitted, incomplete, or illegible
(3) Signature omitted or not original
(4) Other:
B. Provider Information section (1) Omitted, incomplete, or legible
(2) Other:
C. Patient Eligibility section (1) Omitted, incomplete, or illegible
(2) Indicates DHS 4073 must accompany claim
(3) Other: C
0
0
P
0
0
C
0
0
0
Il. DHS 4073 CHDP Eligibility Information Form
» The DHS 4073 must: Q (1) Have original signature—photocopy is not acceptable.
Q (2) Be completed, l.e., each question answered
OQ (3) Be signed by a parent or guardian
QO (4) Be accompanied by PM 160
a (5) Other:
il. Other (Explain.)
MANUAL EDIT LETTER |
DHS 4099 (3/90) C-0
APPENDIX D
PROVIDER STATUS AND
PAYMENT APPEAL PROCESS
PROVIDER STATUS AND
PAYMENT APPEAL PROCESS
When it has been determined that:
(A) A provider or prospective provider does not or could not meet the requirements of the
community CHDP Program:
or,
(B) A provider has:
(1) Become indebted to the Department for monetary reimbursement as a result of the
Department's overpayments for the provider's inappropriate billing of claims; or,
(2) Submitted claims to the CHDP Program which are not in compliance with existing
requirements for full or partial payment.
then, that provider or prospective provider shall be notified in writing by the Community CHDP
Program or the Department of the reason(s) for the action taken and that recourse may be
sought through the following processes (a) or (b) as applicable.
(a) Providers or prospective providers of services with a grievance, complaint, or appeal
concerning the action taken regarding their status as a CHDP provider as stated in A
above, shall direct their grievance, complaint, or appeal as follows:
(1) The providers shall initiate action by submitting a grievance, complaint, or appeal in
writing, within 90 days of the action precipitating the grievance, complaint, or appeal
to the County Administrator of the organizational unit to which the Community
CHDP Program is responsible, identifying the action taken regarding their status as a
CHDP provider.
(2) The County Administrator shall acknowledge the written grievance, compliant or
appeal within 15 days of its receipt.
(3) The County Administrator shall review the merits of the grievance, complaint, or
appeal, may ask for additional information, or may hold an informal meeting with the
provider involved and shall send a written report of conclusion and reasons therefore
to the provider within 30 days of the acknowledgment of the receipt of the grievance,
complaint, or appeal.
(4) The provider may, within 90 days of the County Administrator's action or failure to
act, refer the grievance, complaint, or appeal to the State CHDP Branch Chief only
after complying with the procedures stated above.
(5) In referring a grievance, complaint, or appeal to the State CHDP Branch Chief, the
provider shall include: a copy of the original written grievance, complaint, or appeal
sent to the County Administrator; a copy of the County Administrator's report on
such grievance, complaint, or appeal and specific finding(s) or conclusion(s) of the
County Administrator with which the provider is dissatisfied.
(6)
(7)
(8)
(9)
(10)
(11)
The State CHDP Branch Chief shall acknowledge the referral of a grievance,
complaint, or appeal within 15 days of its receipt.
The State CHDP Branch Chief shall review the written documents submitted in the
provider's referral. The State CHDP Branch Chief may ask for additional
information, or may hold an informal meeting with the involved parties, and shall
send a written report of conclusion and reasons therefore to the provider and County
Administrator within 30 days of the acknowledgment of the receipt of the grievance,
complaint, or appeal.
The provider may, within 90 days of the State CHDP Branch Chief's action or failure
to act, refer the grievance, complaint, or appeal to the Director of the Department of
Health Services only after complying with the procedures as stated above.
In referring a grievance, complaint, or appeal to the Director, the provider shall
include: a copy of the original written grievance, complaint, or appeal sent to the
County Administrator and the State CHDP Branch Chief; a copy of the County
Administrator's and State CHDP Branch Chief's report on such grievance, complaint,
or appeal; and specific finding(s) or conclusion(s) of the County Administrator and
State CHDP Branch Chief with which the provider is dissatisfied.
The Director shall acknowledge the referral of a grievance, complaint, or appeal
within 15 days of its receipt.
The Director shall review the written documents submitted in the provider's referral.
The Director may ask for additional information or may hold an informal meeting
with the involved parties. The Director shall send a written report of conclusion and
reasons therefore to the provider, County Administrator, and the State CHDP Branch
Chief within 60 days of receipt of referral from the provider.
Providers shall initiate action by submitting a grievance, complaint, or appeal in writing,
within 90 days of the action precipitating the grievance, complaint, or appeal, to the State
CHDP Branch Chief identifying the action taken regarding their indebtedness to the
Department or identifying the claim(s) involved and specifically describing the disputed
action or in action regarding such claim(s).
(1)
(2)
(3)
Providers shall initiate action by submitting a grievance, complaint, or appeal in
writing, within 90 days of the action precipitating the grievance, complaint, or
appeal, to the State CHDP Branch Chief identifying the action taken regarding their
indebtedness to the Department or identifying the claim(s) involved and specifically
describing the disputed action or in action regarding such claim(s).
The State CHDP Branch Chief shall acknowledge the written grievance, complaint, or
appeal within 15 days of its receipt.
The State CHDP Branch Chief shall review the merits of the grievance, complaint, or
appeal, may ask for additional information, or may hold an informal meeting with the
provider involved, and shall send a written report of conclusion and reasons therefore
to the provider within 30 days of the acknowledgment of the receipt of the grievance,
complaint, or appeal.
D-2
(4)
(5)
(6)
(7)
The provider may, within 90 days of the State CHDP Branch Chief's action or failure
to act, refer a grievance, complaint or appeal to the Director of the Department of
Health only after complying with the procedures as stated above.
In referring a grievance, complaint, or appeal to the Director the provider shall
include: a copy of the original written grievance, complaint, or appeal sent to the
State CHDP Branch Chief; a copy of the State CHDP Branch Chief's report on such
grievance, complaint, or appeal; and specific finding(s) or conclusion(s) of the State
CHDP Branch Chief with which the provider is dissatisfied.
The Director shall acknowledge the referral of a grievance, complaint, or appeal
within 15 days of its receipt.
The Director shall review the written documents submitted in the provider's referral.
The Director may ask for additional information or may hold an informal meeting
with the involved parties. The Director shall send a written report of conclusion and
reasons therefore to the provider and the State CHDP Branch Chief within 60 days of
receipt of referral from the provider.
The State Maternal, Child, and Adolescent Health Board, having reviewed and approved this
appeal process, has issued a standing recommendation to the Director in accordance with
Section 320.5(j) of the Health and Safety Code. The recommendation states that, in each
instance of appeal, this appeal process be followed and that the Director is the final level of
appeal unless a specific request is made by the Board to review and comment on an appeal.
Any further action on the part of the provider must be judicial in nature.
APPENDIX E
MEDI-CAL CARD CODE REFERENCES
»
RCA
RMA/EMA
AAP-Federal
AAP/AAC-Non-
Federal
EA-UP
INFANT-OBRA
ECA
BLIND
BLIND-INC
BLIND-MN
BLIND-PICKLE
ELIG.
BLIND-MN SOC
BLIND-IHSS
AFDC-FG
AFDC-FG-State
Only
AFDC-U-State
Only
Claims
Requires
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
DHS 4073
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Programs
AFDC-MN
AFDC-U
Disabled-Cobra
AFDC-MN SOC
EDWARDS v. MYERS
FOUR MO. CONT.
AFDC-FC/Non-
Federal
AFDC-FC Federal
EA-ANEC
PREG-CITIZEN
185%
FC
AFDC-FC-20% SS
INFANT 185%
FULL MEDI-CAL
PREG-OBRA 185%
PREG-OBRA 185%
GUIDE TO CHDP ELIGIBILITY VERIFICATION REQUIREMENTS FOR MEDI-CAL AID TYPES
Claims
Requires
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
1/or 2/
Medi-Cal ID#
Medi-Cal ID#
Medi-Cal ID#
1/or 2/
1/ or 2/
1/ Infants are eligible for CHDP service reimbursement using the mother's Medi-Cal identification number for CHDP services during the
month of birth and the following month.
2/ Females with this aid type under 19 years of age may be eligible for CHDP service reimbursement with completion of the DHS 4073.
NOTE: Response to Medi-Cal eligibility question on the DHS 4073 is "NO" with this aid type.
%
MEDI-CAL AID CODES AND DEFINITIONS®
AAP/AAC
State Only
DEFINITION
Refugee Cash Assistance—
Includes unaccompanied children. Refugees from
Cambodia, Laos, Vietnam, and all other refugees who
are eligible may receive benefits during their first 12
months in the United States. Unaccompanied children
are not subject to the 12-month limitation provision.
Refugee Medical Assistance/Entrant Medical
Assistance—
Refugees and entrants who are not otherwise eligible for
Medi-Cal under federally funded AFDC, SSI/SSP, MN,
or Medically Indigent Child Programs may be eligible for
Medi-Cal through the special federal programs of
Refugee Medical Assistance (RMA) or Entrant Medical
Assistance (EMA) during first 12 months in U.S.
Adoption Assistance Program—
A program to facilitate the adoption of hard-to-place
children who would require permanent foster care
placement without such assistance.
Adoption Assistance Program/Aid for Adoption Children
See Aid Code 03 for definition of AAP. The Aid for
Adoption of Children cases are eligible for state funded
financial assistance through the Adoption Assistance
Program providing an Aid for the Adoption of Children.
Agreement was executed prior to October 1, 1982.
*Medi-Cal identification numbers including these aid codes (third and fourth digit of number)
are used on the PM 160s to verify CHDP reimbursement eligibility unless indicated otherwise
herein.
Revised 8-28-90
# J
CODE PROGRAM DEFINITION
06 EA-UP Emergency Assistance-Unemployed Parent—
Provides assistance for 30 days to certain families who
are not eligible for the federal AFDC-U program. These
families are deprived due to the unemployment of the
principal wage earner who is living in the home. The
unemployed parents over 21 years of age are not eligible
for Medi-Cal. Persons under 21 years of age (including
unemployed parent(s) and pregnant women over 21
years of age are eligible for Medi-Cal.
07* INFANT-OBRA Infant— Undocumented Alien/Temporary Visa
200% (OBRA 86)—
Provides emergency services only for infants
under one year of age, and beyond one year when
continuous inpatient status began before and
continues beyond the first birthday, with family
income at or below 200% of the federal poverty
level.
08 ECA Entrant Cash Assistance—
Cuban/Haitian entrants, including
unaccompanied children who are eligible, may
receive Entrant Cash Assistance benefits during
their first 12 months in the United States. (For
entrants, the 12 months begins with their date of
parole). Unaccompanied children are not subject
to the 12-month limitation provision.
20 BLIND SSI/SSP Aid to the Blind—
A cash assistance program administered by the
Social Security Administration which pays a cash
grant to needy blind persons of any age.
23 BLIND-LTC Aid to the Blind-Long-Term-Care Status—
Persons who meet the federal criteria for
blindness, are medically needy, and are in long-
term care status. Long-Term Care is inpatient
medical care which lasts for more than the month
of admission and is expected to last for at least
one full calendar month after the month of
admission.
*Requires completion of CHDP Eligibility Form (DHS 4073) to verify eligibility.
Response to question on DHS 4073 regarding Medi-Cal eligibility is "NO" with this
aid type.
E-3
CODE
26
27
28
30
32
PROGRAM
BLIND-MN
BLIND-PICKLE
ELIG.
BLIND-MN-SOC
BLIND-IHSS
AFDC-FG
AFDC-FG
State-only
DEFINITION
Aid to the Blind-Medically Needy—
Persons who meet the federal criteria for
blindness and do not wish or are not eligible for a
cash grant, but are eligible for Medi-Cal only. No
share of cost required of the beneficiaries.
Aid to the Blind-Pickle Eligibles—
Persons who meet the federal criteria for
blindness, and were eligible for and receiving
SSI/SSP and Title II benefits concurrently in any
month, and were subsequently discontinued from
SSI/SSP but would be eligible for SSI/SSP if their
Title II cost-of-living increases were disregarded
(Lynch v. Rank).
Aid to the Blind-Medically Needy, Share of Cost—
See Aid Code 24 for definition of BLIND-MN.
Share of cost is required of the beneficiaries.
Aid to the Blind-In-Home Supportive Services—
Persons who meet the federal definition of
blindness, receiving In-Home Supportive Services,
but not a SSI/SSP cash grant, and using their
net income in excess of the cash grant maximum
payment level to pay toward In-Home Supportive
Services.
Aid to Families with Dependent Children-Family
Group (FFP)—
Aid to families with dependent children in a
family group in which the child(ren) is deprived
because of the absence, incapacity, or death of
either parent.
Aid to Families with Dependent Children-Family
Group-State-only—
Aid to families in which a child is deprived
because of the absence, incapacity, or death of
either parent, and which do not meet all federal
requirements, but State rules require that the
individual(s) be aided. Examples of these
recipients are the pregnant women with no other
eligible children prior to the last trimester of her
pregnancy, and assistance units which have
qualified for aid because of a State court decision
but do not meet all federal requirements.
CODE
34
35
36
37
38
39
PROGRAM
AFDC-U
State only
AFDC-MN
AFDC-U
DISABLED-
COBRA-
WIDOW(ERS)
AFDC-MN-SOC
EDWARDS
TRANSITIONAL
MEDI-CAL
DEFINITION
Aid to Families with Dependent Children-Unemployed
Parent-State-only—
Aid to families in which a child is deprived because of
the unemployment of a parent living in the home and
such parent is not eligible for federal funds because
he/she does not meet the federal eligibility
requirements.
Aid to Families with Dependent Children-Medically
Needy—
Families with deprivation of parental care or support
who do not wish or are not eligible for a cash grant, but
are eligible for Medi-Cal only. No share of cost required
of the beneficiaries.
Aid to Families with Dependent Children-Unemployed
Parent—
Aid to families in which a child is deprived because of
the unemployment of a parent living in the home and
the unemployed parent meets all federal eligibility
requirements.
Aid to Disabled Widow({er)—
Persons who began receiving SSA before age 60 who
were eligible for and receiving SSI/SSP and Title 1I
benefits concurrently and were subsequently
discontinued from SSI/SSP but would be eligible to
receive SSI/SSP if their Title II disabled widow/ers
reduction factor and subsequent COLAs were
disregarded. No share-of-cost required of the
beneficiaries in accordance with the provisions of
COBRA.
Aid to Families with Dependent Children-Medically
Needy, Share-of-Cost—
See Aid Code 34 for definition of AFDC-MN. Share-of-
cost is required of the beneficiaries.
Continuing Medi-Cal Eligibility—
Edwards v. Kizer court order provides for
uninterrupted, no share-of-cost Medi-Cal benefits for
families discontinued from AFDC until the family's
eligibility or ineligibility for Medi-Cal only has been
determined and an appropriate Notice of Action sent.
Six Months Continuing Eligibility—
Persons discontinued from cash grant due to increased
earnings, increased hours of employment, or loss of the
$30 and 1/3 disregard but eligible for Medi-Cal only.
E-5
CODE
42
43
44*
45
46
47
AFDC-FC/Fed
EA-ANEC
PREGNANT-
CITIZEN 185%
FC
AFDC-FC 20%
SS
INFANT 185%
FULL MEDI-CAL
DEFINITION
Aid to Families with Dependent Children-Foster Care
(non-Fed)—
The purpose of the Aid to Families with Dependent
Children-Foster Care Program is to provide financial
assistance for those children who are in need of
substitute parenting and who have been placed in
foster care.
Aid to Families with Dependent Children-Foster Care
(Federal)—
See Aid Code 40 for definition of Foster Care Program.
Emergency Assistance-Abused, Neglected, or Exploited
Children—
Provides payments and/or services for a child and/or
the child's family when the child is being, or is in
immedia te danger of being abused, neglected, or
exploited. The EA-ANEC program has three
components: Emergency Assistance-Family Services,
Emergency Assistance-Emergency Shelter Care, and
Emergency Assistance-Foster Care.
Pregnant-Citizen/Lawful Permanent Resident/PRUCOL,
Conditional Resident—
Provides family planning, pregnancy related, and
postpartum services for any age female with family
income at or below 185 percent of poverty level.
Foster Care- Under 21-Supported in whole or in part by
Public Funds—
Children in foster care under 21 years of age whose
needs are met in whole or in part by public funds other
than AFDC-FC.
Aid to Families with Dependent Children-Foster Care-
20% Social Security Disregard—
See Aid Code 40 for definition of AFDC-FC.
Infant-citizen/lawful permanent resident/PRUCOL
conditional resident—
Provides full Medi-Cal benefits to infants until their first
birthday, and beyond one year when continuous
inpatient status began before and continues beyond the
first birthday, with family income at or below 185
percent of the federal poverty level.
*Mother's Medi-Cal identification number is only valid when used for the infants CHDP
services during the month of birth and the following month. Pregnant females under 19 years
with this aid type may qualify for CHDP service reimbursement with a completed DHS 4073.
Note: Response to DHS 4073 question about Medi-Cal eligibility is "NO" with this aid type.
E-6
49*
51
52*
54
PROGRAM
PREGNANT-
OBRA 185%
PREGNANT-
IRCA 185%
IRCA AMNESTY
ALIEN FULL
MEDI-CAL
IRCA AMNESTY
ALIEN
RESTRICTED
MEDI-CAL
FOUR MO.
CONT.
DEFINITION
Pregnant-Undocumented Alien Status/Temporary Visa
(OBRA 86)—
Provides family planning, pregnancy related, and
postpartum services to females of any age with family
income at or below 185 percent of federal poverty level.
Pregnant-Immigration Reform and Control Act-Alien—
Provides for family planning, pregnancy related, and
postpartum services to females of any age with family
income at or below 185% of the federal poverty level.
Immigration Reform & Control Act-Alien-Full
Medi-Cal—
The Immigration Reform & Control Act of 1986 (IRCA)
provides for a State Legalization Impact Assistance
Grant (SLIAG) to reimburse the 50% State costs for
providing benefits to Medi-Cal eligible amnesty aliens
(pre-1982 legalization), granted temporary or
permanent resident status under IRCA, who are Aged,
Blind, Disabled (ABD) or children under 18. Share of
cost may be required.
Immigration Reform & Control Act-Alien-Restricted
Medi-Cal—
IRCA provides SLIAG funds to reimburse the 50% State
costs for providing emergency & pregnancy-related
Medi-Cal benefits to eligible amnesty aliens (pre-1982
legalization status), granted temporary or permanent
resident status under IRCA, who are not ABD or
children under 18. Share of cost may be required.
Four Month Continuing Eligibility—
Persons discontinued from AFDC due to the increased
collection of child/spousal support payments, but are
eligible for Medi-Cal only.
*Mother's Medi-Cal identification number is only valid when used for the infant's CHDP
services during the month of birth and the following month. Pregnant females under age 19
years with this aid type may qu
4073. Note: Response to DHS 4
type.
alify for CHDP service reimbursement with a completed DHS
073 question about Medi-Cal eligibility is "NO" with this aid
E-7
CODE
57*
58*
59
60
{
pA
PROGRAM
IRCA SAW/RAW
ALIEN FULL
MEDI-CAL
IRCA SAW/RAW
ALIEN
RESTRICTED
MEDI-CAL
OBRA ALIEN
RESTRICTED
MEDI-CAL
TRANSITIONAL
MEDI-CAL
DISABLED
DEFINITION
Immigration Reform & Control Act-Special Agricultural
Worker/Replacement Agricultural Worker Alien Full
Medi-Cal—
IRCA provides SLIAG to reimburse the 50% State costs
for providing Medi-Cal benefits to eligible Special
Agricultural Worker (SAW) or Replenishment
Agricultural Worker (RAW) aliens granted temporary or
permanent resident status under IRCA, who are ABD or
children under 18. Share of cost may be required.
Immigration Reform & Control Act-Special Agricultural
Worker/Replacement Agricultural Worker Alien-
Restricted Medi-Cal—
IRCA provides SLIAG funds to reimburse the 50% state
costs for providing emergency and pregnancy-related
Medi-Cal benefits for eligible Special Agricultural
Worker (SAW) or Replenishment Agricultural Worker
(RAW) aliens granted temporary or permanent resident
status under IRCA, who are not ABD or children under
18. Share of cost may be required.
Omnibus Budget Reconciliation Act-Alien-Restricted
Medi-Cal—
The Omnibus Budget Reconciliation Act of 1986 (OBRA)
allows emergency benefits, including emergency labor
and delivery to Medi-Cal eligible undocumented and
non-immigrant aliens. These aliens are also eligible for
State-only pregnancy-related services.
An additional six months Continuing Eligibility—
Persons discontinued from AFDC due to the expiration
of the $30 plus 1/3 disregard, increased earnings or
employment, but eligible for Medi-Cal only, may receive
this extension of transitional Medi-Cal. See Aid Code
39.
SSI/SSP Aid to the Disabled—
A cash assistance program administered by the Social
Security Administration which pays a cash grant to
needy persons who meet the federal definition of
disabled.
*Mother's Medi-Cal identification number is only valid when used for the infant's CHDP
services during the month of birth and the following month. Any persons under age 19 years
with this aid type may qualify for CHDP service reimbursement with a completed DHS 4073.
Note: Response to DHS 4073 questions about Medi-Cal eligibility is "NO" with this aid type.
E-8
CODE
65
66
67
68
PROGRAM
DISABLED-LTC
DISABLED-MN
DISABLED-SGA/
ABD-MN (IHSS)
Soc/No Soc
DISABLED-
PICKLE ELIG.
DISABLED-MN-
SOC
DISABLED-IHSS
DEFINITION
Aid to the Disabled-Long-Term-Care Status—
Persons who meet the federal definition of disabled who
are medically needy and in long-term care status. See
Aid Code 23 for definition of Long-Term Care.
Aid to the Disabled-Medically Needy—Persons who meet
the federal definition of disabled and do not wish or are
not eligible for a cash grant, but are eligible for Medi-
Cal only. No share of cost required of the beneficiaries.
Aid to the Disabled-Substantial Gainful Activity/Aged,
Blind, Disabled-Medically Needy (In-Home Supportive
Services)—
Persons who (a) were once determined to be disabled in
accordance with the provisions of the SSI/SSP program
and were eligible for SSI/SSP, but became ineligible
because of engagement in substantial gainful activity as
defined in Title XVI regulations. They must also
continue to suffer from the physical or mental
impairment which was the basis of the disability
determination. Or (b) are aged, blind, or disabled
medically needy and have the costs of in-home
supportive services deducted from their monthly
income. Share of cost may be required of the
beneficiaries.
Aid to the Disabled-Pickle Eligibles—
Persons wh meet the federal definition of disabled and
are covered by the provisions of the Lynch v. Rank
lawsuit. See Aid Code 26 for definition of Pickle
Eligibles.
Aid to the Disabled-Medically Needy, Share of Cost—
See Aid Code 64 for definition of Disabled-MN. Share of
cost is required of the beneficiaries.
Aid to the Disabled-In-Home Supportive Services—
Persons who meet the federal definition of disabled and
are eligible for In-Home Supportive Services. See Aid
Code 28 for definition of eligibility for In-Home
Supportive Services.
{ »
AID
CODE PROGRAM
89 INFANT-OBRA
185%
70** PREGNANT-
OBRA 200%
71* DP/DSP
72 CHILD 133%
FULL SCOPE
MEDI-CAL
73* TPN /TPN-SUPP
DEFINITION
Infant-Undocumented Alien/Temporary Visa (OBRA 86)
Provides emergency services only for infants under one
year of age and beyond one year when continuous
inpatient status began before and continues beyond the
first birthday, with family income at or below 185
percent of the federal poverty level.
Pregnant-Citizen/lawful permanent resident
PRUCOL/Conditional status and undocumented
status/temporary visa (OBRA 86)—
Provides family planning, pregnancy related, and
postpartum services under the state only funded
expansion of the Medi-Cal program for a person having
income at or below 200% of the federal poverty level.
Medi-Cal Dialysis Only and Dialysis Supplement
Programs—
Persons of any age who are eligible only for dialysis and
related services or are eligible for the Medically Needy or
Medically Indigent Programs and also meet eligibility
requirements for the Dialysis Supplement program.
Child-Citizen/lawful permanent resident/PRUCOL/
conditional status—
Provides full scope Medi-Cal benefits for children ages
one through five with family income at or below 133% of
the federal poverty level.
Medi-Cal TPN Only and TPN Supplement Programs—
Persons of any age who are eligible for parenteral
hyperalimentation services only or are eligible for
Medically Needy or Medically Indigent Programs and
also meet eligibility requirements for the TPN
Supplement Program.
*Requires completion of DHS 4073 to verify CHDP reimbursement eligibility. Response to DHS
4073 question about Medi-Cal eligibility is "NO" with this aid type.
ssMother's Medi-Cal identification number is valid only when used for the infant's CHDP
services during the month of birth and the following month. Females under 19 years old with
this aid type may be eligible for CHDP service reimbursement with a completed DHS 4073.
Note: Response to Medi-Cal eligibility question on DHS 4073 is "NO" for this aid type.
CODE PROGRAM DEFINITION
74" CHILD-OBRA Child-Undocumented Alien/Temporary Visa (OBRA 86)}—
133% Provides for emergency services only for children ages
one through five years whose family income is at or
below 133% of the federal poverty level.
75** PREGNANT- Pregnant-IRCA Amnesty Alien—
IRCA 200% Provides family planning, pregnancy related, and
postpartum services for amnesty aliens under the state
only funded expansion of the Medi-Cal program for a
person having income at or below 200% of the federal
poverty level.
76** 60-DAY 60-Day Postpartum Program—
POSTPARTUM Provides assistance to women who, while pregnant,
were eligible for, applied for, and received Medi-Cal
benefits, so that they may continue to be eligible for all
postpartum and pregnancy related medical assistance
as though they were pregnant. This coverage begins on
the last day of pregnancy, continues for 60 days, and
ends on the last day of the month in which the 60th
day occurs.
27 RDP-FG Refugee Demonstration Project-Family Group—Provides aid
to refugee families with dependent children in a family
group in which all of the children are deprived because of
the absence, incapacity, or death of either parent, and who
would normally qualify for the federal AFDC program, who
reside in areas in which SDDS-funded and/or targeted
assistance employment/training programs are available,
and who are RDP time-eligible.
*Requires completion of DHS 4073 to verify CHDP reimbursement eligibility. Response to DHS 4073
question about Medi-Cal eligibility is "NO" with this aid type.
**Mother's Medi-Cal identification number is valid only when used for the infant's CHDP services
“during the month of birth and the following month. Females under 19 years old with this aid type
may be eligible for CHDP services reimbursement with a completed DHS 4073. Note: Response to
Medi-Cal eligibility question on DHS 4073 is "NO" for this aid type.
E-11
CODE
79
82
86*
87*
PROGRAM
RDP-U
INFANT 200%
FULL MEDI-CAL
MI-C-SOC
MI-CP
MI-CP-SOC
DEFINITION
Refugee Demonstration Project-Unemployed Parent—
Provides aid to refugee families with dependent children
in a family group in which one or more children are
deprived because of the unemployment of the parent(s)
and who would normally qualify for the federal AFDC
program, who reside in areas in which SDSS-funded
and/or targeted assistance employment/training
programs are available, and who are RDP time-eligible.
Infant-Citizen Lawful permanent resident/PRUCOL/
conditional resident—
Provides full Medi-Cal benefits to children under the age of
one year, and beyond one year when continuing inpatient
status, with family income at or below 200% of the federal
poverty level.
Medically INdigent-Children-Under 21-No Share of Cost—
Persons under 21 years of age (married or not married) who
meet the eligibility requirements of medically indigent.
Share of cost is required of beneficiaries.
Medically Indigent Children-Under 21 Share of Cost—
Persons under 21 years of age (married or not married) who
meet the eligibility requirements of medically indigent.
Share of cost is required of beneficiaries.
Medically Indigent-Confirmed Pregnancy-21 Years or Older-
No Share of Cost—
Persons, age 21 or older, with confirmed pregnancy, who
meet the eligibility requirements of medically indigent. No
Share of Cost is required of beneficiaries.
Medically Indigent-Confirmed Pregnancy-21 Years or Older-
Share of Cost—
Persons age 21 or older, with confirmed pregnancy, who
meet the eligibility requirements of medically indigent.
Share of cost is required of beneficiaries.
sMother's Medi-Cal identification number is valid only when used for the infnat's CHDP
services during the month of birth and the following month. Females under 19 years with this
aid type may be eligible for CHDP services reimbursement with a completed DHS 4073. Note:
Response to DHS 4073 question about Medi-Cal eligibility is "No" with this aid type.
E-12
OTHER COVERAGE CODES
CARRIER CODE
Blue Cross
Champus
Prudential
Aetna
First Farwest Insurance Co.
American General
Mutual of Omaha
Metropolitan Life
John Hancock
Kaiser
PHP/HMP, not otherwise specified
Equicor/Equitable
Ross-Loss
Blue Shield
Travelers
Connecticut General (CIGNA)
Variable not otherwise specified
Great West Life Assurance
Provident Life and Accident
Principal Financial Group
Pacific Mutual Life Insurance
Alta Health Strategies Inc.
American Asociation of Retired Persons (AARP)
Allstate Life Insurance
New York Life Insurance
Crown Life Insurance C
o
N
W
N
E
L
C
C
H
O
V
A
O
I
A
C
I
O
T
I
O
O
O
W
Other coverage, carrier not specified A
Multiple Coverage, not specified M
Blue Shield X
Blue Cross (code being phased out) Y
Blue Cross Z
No other coverage N or
Blank
*Other Coverage Code K, P, and R require the patient to obtain CHDP services through their
Health Care Plan (CHDP). A CHDP health assessment will not be reimbursed through the Fee-
For-Service system if any of these codes are present on the Medi-Cal card. All other codes
listed are payable unless a numeric HCP code is also listed which would prevent payment.
(See Appendix, page E-15 for list of HCP codes.)
Medi-Cal Recipient ID Card (MC 300, Green)
(Issued by State)
RETRO: NOV 88 02/15/1981 F LASTNAME FIR55
SSA# 545896715 2 5458967156F 27
21188MS8IN
LASTNAME FIR55
County Identification Number —————— 55-27-0017953-1-01 **6°** 5458967156F 27
FIRSTNAME I LASTNAME 21188M8IN
LASTNAME FIR55
BOX A101 5458967156F 27
TWAIN HARTE, CA 95383 21188P8IN
LASTNAME FIR55
MEDSID 545896715 5458967156F 27
Social Security Number > MO12 21188p8ln
LASTNAME FIR55
SOC: 0000 Q/C:M 5458967156F 27
L322 21188p8in
WHERE TO FIND THE "OTHER COVERAGE CODE":
CHECR DIGIT COUNTY CODE
RECIPIENT NAME
SEX
SSN (TASTNAME \ py al
MEDICARE 5458967 156F 27
INDICATOR 21188P8IN LS RESTRICTED SERVICES
HEALTH CARE PLAN CODE
VALID MONTH
YEAR (OTHER COVERAGE CODE
SERVICE LEVEL BIRTH YEAR
E-14
MEDI-CAL HEALTH CARE PLAN CODES
The following Medi-Cal Health Care Plan or Prepaid Health Plan codes when present on Medi-
Cal identification card will result in denial of reimbursement for the CHDP services on claims
submitted for payment. Patients enrolled in these health care plans must request CHDP services
from their plan. See Medi-Cal Identification Card illustration below for code location.
CODE PLAN NAME COUNTY
002 Cigna Health Plans of California Los Angeles
003 Family Health Program Los Angeles
004 Peak Health Plan San Diego
005 Family Health Program (FHP Inc) Orange
006 Amerimed Los Angeles
012 United Health Plan/Watts Orange
013 Health Plan Plus Santa Clara
014 United Health Plan San Diego
018 Universal Care Los Angeles
019 Universal Care Orange
020 Peak Health Plan Orange
027 INA Health Plan of California Riverside
028 Kaiser Foundation Health Plan Los Angeles
029 Community Health Group San Diego
032 United Health Plan/Watts Los Angeles
045 Contra Costa Health Plan Contra Costa
076 Kaiser Foundation Health Plan Orange
077 Kaiser Foundation Health Plan Riverside
078 Kaiser Foundation Health Plan San Bernardino
079 Kaiser Foundation Health Plan San Diego
090 Kaiser Foundation Health Plan San Francisco
098 Community Health Plan Los Angeles
101 Kaiser Foundation Health Plan Contra Costa
; OH 4 YEAR DATE x rE “ea™ LLOMENT SEX
Of fLGISUTY LL
EDI-CAL IDENTIFICATION.CARD
OATY/THE Sack OF
PEOT PROJECT MAME
NN VALID: KOV 89 o2nsnse Ff |LASTNAME FIRSS
TELEPHONE NUMBER NG S4S82671S6F 27
ine Why PCCM-PRIMARY CARE MED GRP 1189MBINEI0
CHECK DIGIT... AUTH (209) 673-3020 LASINAME FIRSS
necirrent 10 —T1 FIRSTNAME Si LASTNAME a rir ol
a BOX A10t LASTHNAME FIRSS
accrrent |, 123 MAIN ST S4SSEETISEF 27
MAME TWAIN HARTE, CA 5383 1183P81MR30
LASTNAME FIRSS
RECIPIENT MEDSID $¢S8%€671S S4S88ET1S6F 27
ADORESS M012 1189PE INGO
i ew LASTNAME FIRSS
COUNTY es SOC: 0000 OCH $4S88671S6F 27
COOWNG | L322 1189P81NE30
a — == eee
STATE CODING —] na en te phelps your
R(OMEINT CHECK SX CouwTY
ups [11 / Coot
\ \ /
LASTNAME / FIRSS
$00at $LCUnily mumets —4 S4SEBET1SEF 2
(183ma1Ng30
NEE
vai10 =0Oul svat veg OF
LasCL
|_—~ #50 COC
A(ITRCTED
-—t"" sancLs
sa(OeCang
teOiCA TOR
v(ak OF
("13 }
Otwuie
COVERAGE COOL
E-15
APPENDIX F
TABLE OF REPORTABLE EVENTS
FOLLOWING VACCINATION
TABLE OF REPORTABLE EVENTS FOLLOWING VACCINATION
Vaccine /Toxoid Event Interval from Vaccination
DTP, P A. Anaphylaxis or anaphylactic shock 24 hours
DTP/Polio B. Encephalopathy (or encephalitis)* 7 days
Combined C. Shock-collapse or hypotonic- 7 days
hyporesponsive collapse®
D. Residual seizure disorder*® (See Aids to Interpretation®)
E. Any acute complication or sequela No limit
(including death) of above events
F. Events in vaccines described in (See package insert)
manufacturer's package insert as
contraindications to additional doses of
vaccinet (such as convulsions)
Measles, A. Anaphylaxis or anaphylactic shock 24 hours
Mumps, and B. Encephalopathy (or encephalitis)* 15 days for measles, mumps, and
Rubella; DT, rubella vaccines; 7 days for DT, Td,
Td, Teta d T toxoids (See Aid
living C. Residual seizure disorder® and 7 toxoids {ce Aldeilo
Interpretation®)
D. Any acute complication or sequela No Limit
(including death) of above events
E. Events in vaccines described in
manufacturer's package insert as
contraindications to additional doses of
(See package insert)
vaccinet
ral Folio A. Paralytic poliomyelitis
—in a non-immunodeficient recipient 30 days
—in an immunodeficient recipient 6 months
—in a vaccine-associated community No limit
B. Any acute complication or sequela
(including death) of above events
C. Events in vaccines described in (See package insert)
manufacturer's package insert as
contraindications to additional doses of
vaccinet
Inachvated A. Anaphylaxis or anaphylactic shock 24 hours
Vecciie B. Any acute complication or sequela No limit
(including death) of abov e event
C. Events in vaccines described in (See package insert)
manufacturer's package insert as
contraindications to additional doses of
vaccinet
*Aids to Interpretation— Shock collapse or hypotonic-hyporesponsive collapse may be evidenced by signs or symptoms
such as decrease in or loss of muscle tone, paralysis (partial or complete), hemiplegia, hemiparosis, loss of color or
turning pale white or blue, unresponsiveness to environmental stimuli, depression of or loss of consciousness, prolonged
sleeping with difficulty erousing, or cardiovascular or respiratory arrest. Residual seizure disorder may be considered to
have occurred if no other seizure or convulsion unaccompanied by fever or accompanied by a fever of less than 102°F
occurred before the first seizure or convulsion after the administration of the vaccine involved. AND, if in the case of
measles, mumps, or rubella-containing vaccines, the first seizure or convulsion occurred within 15 days after vaccination
OR in the case of any other vaccine, the first seizure or convulsion occurred within 3 days after vaccination, AND, if two
or more seizures or convulsions unaccompanied by fever or accompanied by a fever of less than 102°F occurred within 1
year after vaccination.
The terms seizure and convulsion include grand mal, petit mal, absence, myoclonic, tonic-clonic, and focal motor seizures
and signs. Encephalopathy means any significantly acquired abnormality of, injury to, or impairment of function of the
brain. Among the frequent manifestations of encephalopathy are focal and diffuse neurologic signs, increased
intracranial pressure, or changes lasting at least 6 hours in level of consciousness, with or without convulsions. The
neurologic signs and symptoms of encephalopathy may be temporary with complete recovery, or they may result in
various degrees of permanent impairment. Signs and symptoms such as high-pitched and unusual screaming, persistent
unconsolable crying, and bulging fontanel are compatible with an encephalopathy, but in and of themselves are not
conclusive evidence of encephalopathy. Encephalopathy usually can be documented by slow wave activity on an
electroencephalogram.
$The health-care provider must refer to the CONTRAINDICATION section of the manufacturer's package for each vaccine.
Source: Reprinted by U. S. Department of Health and Human Services, Public Health Service, Centers for Disease Control,
from the MMWR, April 8, 1988, Vol. 37, No. 13, page 198.
F-1
STATE OF CALIFORNIA—HEALTH AND WELFARE AGENCY GEORGE DEUKMEJIAN, Governor
DEPARTMENT OF HEALTH SERVICES
714/744 P STREET
SACRAMENTO, CA 95814
(916) 322-4780
November 26, 1986
CHDP Program Letter #86-19
To: Community Child Health and Disability Prevention Program Directors
and Deputy Directors
Subject: Revised CHDP Medical Guidelines for Free Erythrocyte Protoporphyrin
(FEP) Blood Lead Level Determination
The attached revisions to the CHDP Medical Guidelines for Blood Lead Level
testing supersede the previous guidelines dated January 21, 1983. Also
attached is a revision of page 6 of the PM 160 Instructions. These revis-
ions are intended for use by providers as a guide in ordering blood lead
level determinations.
We are concerned that many children at risk are not being screened.
Providers should be encouraged to screen for elevated blood lead whenever
a child's history suggests possible lead exposure.
Please distribute this Provider Information Notice to each provider in your
county and return the "Report of Distribution" to:
Child Health and Disability
Prevention Branch
714 P Street, Room 1792
Sacramento, CA 95814
If you have any questions, please contact your Regional Consultant.
“Ws i,
Nicholas Diez, Chief
Family Health Division
Attachments
STATE OF CALIFORNIA—HEALTH AND WELFARE AGENCY GEORGE DEUKMEJIAN, Governor
DEPARTMENT OF HEALTH SERVICES Peay
714/744 P STREET
SACRAMENTO, CA 95814 ts
(916) 322-4780
November 26, 1986
CHDP Provider Information Notice #86-12
TO: CHDP Providers
Subject: Revised Medical Guidelines for Blood Lead Level Testing
Lead poisoning has been recently recognized as a potentially significant health
problem for California children. New epidemiological evidence has shown
children with subclinical lead poisoning have a higher incidence of learning
problems and lower IQs when compared to their classmates and their own parents.
This finding has resulted in revision of the recommendations on blood lead
levels from the Centers for Disease Control. It is important infants and
children be screened for elevated blood lead if their history suggests possible
lead exposure even though they may be asymptomatic. Prevention of learning
problems is important and subclinical lead poisoning is one of the few poten-
tially treatable causes. It is essential providers of child health care
recognize the possibility of this disorder and screen appropriately.
The CHDP Program has revised its criteria for blood lead level testing to
concur with the recommendations published by the Centers for Disease Control
(CDC) in January 1985.
Under the new criteria, any child with a Free Erythrocyte Protoporphyrin (FEP)
of 35 micrograms or greater per 100 ml of blood should have a blood lead level
determination. If the blood lead level is above 25 micrograms per 100 ml, a
referral should be made for confirmatory laboratory testing, diagnosis, and
treatment.
The highest priority for checking Free Erythrocyte Protoporphyrin (FEP) levels
should be in children between 12 and 36 months of age living in dilapidated
housing. If an elevated blood lead is confirmed, siblings and other children
at risk should have FEP levels checked.
Attached are revised pages for your Medical Guidelines (pages 2 and 26) and
the PM 160 Instructions (page 6).
There are many potential environmental sources that can cause lead poisoning.
However, ingestion of lead-based paint by children continues to be the single
greatest cause of acute lead poisoning. In California there are an estimated
one and one-half million homes containing lead-based paint, all of which pose
a potential threat to children living in them.
N, ~
In addition, in the past few years it has been discovered that some folk
medicines used by various ethnic groups have also caused lead poisoning, for
example:
o Hispanic: Azarcon, Greta, Liza, Maria Luisa, Alarcon, Coral, Rueda.
o H'mong: Pay-Loo-AH.
o East Indian: Surma, Ghasard, Bala Goli, Kandu.
o Arabic: Alkohl. Used as a cosmetic and also used for skin
infections and to sterilize the umbilical cord. Bokhoor.
o Middle East: Ceruse-Cerrusite.
o Armenian: Surma.
Please be on the lookout for any of your patients who may be exposed to lead.
Parents should be routinely asked if they live in older homes: if the child
eats soil, paint, paper, painted toys; if the parents are exposed to lead in
their workplace (several child lead poisoning cases have occurred when parents
carried lead dust home on their clothing); or if pottery is used to cook or
store food.
If you know of additional sources that contain lead, or you have any questions,
please contact your local program staff. Remember, children may not be
symptomatic but may have dangerous levels of blood lead that can eventually
lead to severe health problems.
If you have any questions, please contact your local CHDP program staff.
Nicholas Diez, Chief Maridee A. Gregory,”M.D., Chief
Family Health Division Maternal and Child Health Branch
Child Health and Disability Prevention Program
HEALTH ASSESSMENT PROCEDURES REQUIRED FOR VARIOUS AGE GROUPS!
AGE OF PERSON BEING SCREENED
Under| 1-2 | 3—4 | 5-6 | 7-9 | 10-12 | 13-15| 16-23 | 2 3 4-5 | 6-8 | 9-12 | 13-16 | 17-20
SCREENING PROCEDURE 1 Mo. | Mos. | Mos. | Mos. | Mos. | Mos. Mos. Mos. | Yrs. | Yrs. | Yrs. | Yrs. Yrs. Yrs. Yrs.
Interval Until | 1 Mo, 2 Mos. [2 Mos. |2 Mos. [3 Mos. | 3 Mos. | 3 Mos. | 6 Mos. | 1Yr. | 1Yr. [2Vrs.|3Vrs.| 4 Yrs. | 4 Yrs. | None
ext Exam
HISTORY AND PHYSICAL EXAMINATION X X X X X X X X X X X X X X X
Dental Assessment
Nutritional Assessment
Developmental History and Assessment
Health Education
VISION SCREENING »
Snellen or Equivalent Visual Acuity Test X2 0 ix X X X X
Clinical Observation : X X X X X X X X X X X X X X X
HEARING SCREENING
Audiometric X? X X X X X
Nonaudiometric X X X X X X X X X
TUBERCULIN TEST? X X X X
LABORATORY TESTS
Hematocrit or Hemoglobin X X X X X X X X
Urine Dipstick or Urinalysis X X X X X
Phenylketonuria (PKU) X
Sickle Cell May be done once if both anemic and from specific target groups (see guidelines).
Free Erythrocyte Protoporphyrin (FEP) May be done only if health history warrants. »
Bload Lead Level May be done only if FEP is above 35 ug/dl.
Gonorrhea Culture® X X X
x4 X Papanicolau (Pap) Smear
IMMUNIZATIONS — administer as X X X X X X X X X X X X X X
necessary to make status current.’
N
NOTE: PERSONS COMING UNDER CARE WHO HAVE NOT RECEIVED ALL THE RECOMMENDED PROCEDURES FOR AN EARLIER AGE SHOULD BE
BROUGHT UP-TO-DATE AS APPROPRIATE.
1 Required unless medically contraindicated or deemed inappropriate by the screening provider or refused by the person.
2 Snellen and audiometric examinations should be done at this age if possible.
3 Recommended more frequently in high risk populations such as recent immigrant and refugee families.
4
5
Recommended only for sexually active adolescents.
“Guide For Use of Selected Vaccines and Toxoids,’’ California Department of Health Services, Infectious Disease Section, July 1980.
Reference: CHDP Legislation, Health and Safety Code, Sections 321.2 and 323.7.
(Rev.8/85) g
| * . bk 25
PAPANICOLAU (PAP) SMEAR
A Papanicolau (Pap) smear is to be done beginning at 17 years, or younger if sexually active. High
risk individuals for cancer-in-situ are those who (1) begin sexual activity in early teen years, and (2)
have multiple partners.
Sexually active individuals should be referred to family planning programs for appropriate services
including yearly Pap smears. :
Referral and Follow-Up
A referral for further evaluation, diagnosis, or treatment is made when the smear is class II or above.
SCREENING PROCEDURES WHEN MEDICALLY INDICATED
PHENYLKETONURIA (PKU)
The CHDP program will reimburse for Phenylketonuria testing done as a repeat test for infants up
to one month of age who were tested in the hospital under 24 hours of age. Children who have not
been tested should be referred in accordance with the local health department protocol for new-
born screening for PKU, galactosemia, and congenital hypothyroidism.
Referral and Follow-Up
If the PKU test is presumptive positive, the child should be referred for diagnosis and treatment.
SICKLE CELL DETERMINATION
Black persons or persons whose ancestors came from areas near the Mediterranean Sea or the Indian
Ocean and have laboratory results showing anemia, i.e., hemoglobin of less than 11 grams or a
hematocrit of 34 percent or less, should be tested to determine their sickle cell status.
The cellulose acetate electrophoresis method must be used.
Request for Screening
If a program recipient who is not anemic and is a member of the target groups described above
requests a screening test for sickle cell anemia or trait, s/he should be referred to the nearest
community-based sickle cell screening program.
Referral and Follow-Up
When the test for sickle cell disease or trait is positive, it is recommended that counseling by a
physician or state-approved counselor be provided. Contact your local CHDP program for assistance
with referral if needed.
Counseling
The purpose of sickle cell counseling is to help the individual or family:
1. Understand the medical facts about the condition, including the diagnosis, the probable
cause of the condition, and the available management for the condition;
2. Understand the way heredity contributes to the condition, and the risk of recurrences in
specified blood relatives;
3. Understand the options for dealing with the risk of recurrences of the. condition;
- a 26
4. Choose the course of action which seems appropriate to them in view of their goals and act
in accordance with that decision; and
5. Make the best possible decision.
FREE ERYTHROCYTE PROTOPORPHYRIN (FEP)
BLOOD LEAD LEVEL
Children with pica behavior are candidates for lead poisoning because sources of lead are readily
available in our environment. Examples of environmental lead sources include paint chips (particu-
larly in old housing), colored magazine pages, contaminated soil, and clothing contaminated at lead
emitting work places. Certain folk medicines are an additional source of lead poisoning for children.
It is strongly recommended that if lead poisoning is suspected, a venous macro blood sample (5 ml.)
be drawn. If this is not possible, four capillary tubes of blood may be drawn: one for FEP, one for
blood lead, and two extra in case of clotting or breakage.
Testing consists of the following laboratory tests:
1. Free Erythrocyte protoporphyrin (FEP) — Only those with an FEP of 35 micrograms per
100 ml. of blood or greater should have a blood lead level.
2. Blood lead level — If the blood lead level is above 25 micrograms per 100 ml,, a referral is
made for diagnosis and treatment including confirmatory laboratory testing. Any child with
a confirmed blood level over 25 micrograms per 100 ml. should be referred to Public Health
Nursing and an environmental investigation should be initiated.
The laboratories conducting FEP or blood lead testing must participate in the State’s or CDC's proficiency testing program for CHDP to reimburse the tests. Prior approval must be obtained from
the State and the local CHDP directors only if routine testing is planned on all children screened.
Questions regarding laboratory analysis should be referred to:
Air and Industrial Hygiene Laboratory
Childhood Lead Program
2151 Berkeley Way
Berkeley, CA 94704
(415) 540-2469/ATSS 571-2469
Questions regarding medical consultation or environmental evaluation may be referred to:
Community Toxicology Unit
2151 Berkeley Way
Berkeley, CA 94704
(415) 540-3063/ATSS 571-3063
CCS covers diagnostic evaluations for possible lead poisoning without regard to income eligibility and will provide for treatment costs, if required, for children whose family income is less than 300%
of the Federal poverty level.
GONORRHEA CULTURE
Cultures for gonorrhea may be done when deemed appropriate by the supervising physician on the basis of the social/sexual history. The issue of appropriate contraceptives should be discussed at this time and a referral made for family planning services if the person is sexually active.
. ~
REPORT OF DISTRIBUTION
PROVIDER INFORMATION NOTICE #86-12
REVISED CHDP MEDICAL GUIDELINES FOR FREE ERYTHROCYTE PROTOPORPHYRIN
(FEP) BLOOD LEAD LEVEL DETERMINATION
TO:
PROVIDER INFORMATION CLERK
CHILD HEALTH AND DISABILITY PREVENTION BRANCH
CALIFORNIA STATE DEPARTMENT OF HEALTH SERVICES
714 P STREET, ROOM 1792
SACRAMENTO, CA 95814
THIS PROVIDER INFORMATION NOTICE WAS SENT TO PROVIDERS IN
COUNTY/COMMUNITY ON
(DATE)
SIGNATURE OF SENDER
PLEASE NOTE THAT NO CHANGE IS TO BE MADE IN THIS NOTICE OR
ATTACHMENTS.
PLEASE COMPLETE THIS FORM AND FORWARD TO ADDRESS SHOWN ABOVE.
THANK YOU FOR YOUR COOPERATION.
i atau itetan btn ies eR
——
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DO NOT EN a E————E———————————
: , - TR i X ERE STS Pep Arle, Ents ALESIS TER AAI RCE JRE SR ATT A WT PARA ET EH Wo SL 0 PEA ERGATA LA ~ Ye 2 iin
SS str Tr RE SRE Na Cs
CLAIM CONTROL NUMBER «
FOR STATE USE ONLY
T ; LAST (FIRST) (INITIAL) FAUST pine ( )
MEDICAL RECORD NO. LA. Code
£1]. ' : ‘ ; : : t i : : ‘ J
: BIRTHDATE AGE SEX (circiey]| PATIENT'S COUNTY OF RESIDENCE CODE TELEPHONE NUMBER NEXT VISIT 1-American Indian * BE Moe, Day Year .
Day Year 2-Asian Fi we pu 125, R "RESPONSIBLE PERSON (NAME) (STREET) ©) @P) Coce $Mex. Amer./Hispa
iL
7-Other ;i
8-Pacific Islander
BLEM SUSPECTED . WC a ET oro a QLLOW UP CODES _ CHDP ASSESSMENT 5 in {4 ob: a No DURE OICATE 08 Now TE DX PENDING/RETURN Vis PROBLEM | INDICATED, Appropriate Column UNDER CAR SCHEDULED '”. Indicate outcome for each suspecten | (AO [NEW | KNOWN 7% 2 quESTOASLE REST, RECHECK 5. REFERRED 10 ANOTHER EXAMIK LEN Screening procedure : D HEDULED semi FOR DX/RX Foe : vA vB C 3. DX MADE AND RX STARTED "6. REFERRAL REFUSED -
REFERRED TO: TELEPHONE NUMBER 01 HISTORY and PHYSICAL EXAM
. 02 DENTAL ASSESSMENT/REFERRAL
REFERRED TO: TELEPHONE NUMBER
~~ 03 NUTRITIONAL ASSESSMENT |
04 Sh EocaTiON COMMENTS/PROBLEMS
05 DEVELOPMENTAL ASSESSMENT
IF A PROBLEM IS DIAGNOSED THIS VISIT, PLEASE ENTER "© 06 SNELLEN OR EQUIVALENT YOUR DIAGNOSIS IN THIS AREA
07 AUDIOMETRIC
- ‘08 HEMOGLOBIN OR HEMATOCRIT
* 09 URINE DIPSTICK
"10 COMPLETE URINALYSIS
"11 TB MULTIPUNCTURE
© "12 TB MANTOUX :
CODE . | OTHER TESTS | SEE CODES ON REVERSE SIDE OF LAST PAGE
A M : HEIGHT WEIGHT BLOOD PRESSURE .
alm
MEMBER
HCT. BIRTH WEIGHT Ki PREPAID
GIVEN TODAY | NOT GIVEN T0DAY | SYSTEM
Now up STIL NT ALREADY REFUSED Z ICD 9 CODES
IMMUNIZATIONS “eR | okTEFoR | oATEFOR | comma _ | | | | |
AGE AGE AGE INDICATED
A 2 C 0
31 POLIO - ORAL THE QUESTIONS BELOW 32DPT DUTa n MUST BE ANSWERED
33MMR(]* Mur MR[P 7 1. Patient is Exposed to Passive (Second Yes O No[] 38 Hib CV ZA Hand) Tobacco Smoke.
: 2. Tobacco Used by Patient. Yes[(] No[]
3. Counseled About/Referred For Yes[] No[] 77 7 7 Tobacco Use Prevention/
7 7 7 Cessation.
AL 4 o
PROVIDER OF SERVICE: Name, Address, PREPRIZ PROACH (00% ns 3] olled in wi 2] 2] Seto red to WIC
CONFIDENT
Teiephone Number (Please Include Area Code)
SITE OF 7 IF OTHER THAN ABOVE: 7
_
WIC req
——
Ea ee
id ik NUMBER
ry
ns OF CALIFORNIA- aid HEALTH AND DISABILITY PREVENTION PROGR
SIGNATURE OF PROVIDER DATE Medi-Cal/CHDP
IAL SCREEN
R—-.:-COA
ING/BILLING REPORT
Fo Fry i i RS Be Paes sn ps Se a Blasx Wabi Sammy Em =
ni P.0. Box 15300
COPY 1 - MAIL TO MEDI-CAL CHOP Sacramente, CA 95351-1300
PM 160 IMCORMATION ONLY (4
ke
.
OTHER TESTS: (PES OTHE) IMMUNIZATIONS: CODES ~~ |
13—Sickle Cell: Electrophoresis 34—Measles
14—Lead: FEP. - 35—Mumps
15—Lead: Blood Lead 36—Rubella
16—VDRL, RPR or ART 37—Hib
17—G.C. Culture 39—Polio: Inactivated
Poli i p
18—Pap Smear Gio Vaccine (IPV)
19—PKU: Blood
20—Chlamydia Culture
21—Pelvic Examination
RELEASE OF INFORMATION NOTICE TO THE RESPONSIBLE PERSON:
The information provided on this form is voluntary and is used by the California Child Health and
Disability Prevention (CHDP) program in accordance with Article 7, Subchapter 13, Title 17 of the
California Administrative Code to monitor program quality, to reimburse providers of health
assessments for their services and to facilitate diagnosis and treatment at the local level for children
found to have health problems. Information provided may be transferred to local health departments
for follow-ups. Refusal to supply the information requested will hamper efforts to monitor this pro-
gram, may delay reimbursement procedures and may delay diagnosis and treatment of health
conditions affecting your child. For access to records containing this information you may contact the
individual listed below. You may also request the location of this information and the categories of
persons who use it.
Chief, Child Health and Disability Prevention Program
Family Health Division
714 P Street, Room 708
Sacramento, CA 95814
(916) 322-4780
CLAIM CONTROL NUMBER ee FOR STATE USE ONLY
00 NOT Tar A ——————
IN BAR AREA
p | PATIENT NAME (LAST) (FIRST) (INITIAL) MEDICAL RECORD NO. 3A
Y
\ ae ya i194 u00GLAss
A BIRTHDATE AGE SEX (arcie| PATIENT'S COUNTY OF RESIDENCE CODE TELEPHONE NUMBER NEXT VISIT 1-American Indian
£ Mo. Day Year Ma. Day Year 2-Asian
: rw ol abl fen BE
R [RESPONSIBLE PERSON (NAME) (STREET) Cm @p Cons Sex Amer Hispar
-yéfule ! En
T 8-Pacific Islander
PROBLEM SUSPECTED ATE OF SERVI Ts
a Enter Follow Up Code oA £ gf 3 Vice FOLLOW UP CODES
CHDP ASSESSMENT! ooo 1 in tT .{: jee NO DI/RX INDICATED OR NOW ‘4. DX PENDING/RETURN VIS:
PROBLEM NDICATED, Appropriate Column : UNDER * SCHEDULED
Indicate outcome for each SUSPECTED a > NEW KNOWN yA QUESTIONS: RESULT, RECHECK 78, REFERRED TO ANOTHER EXAMINt
screening procedure FEES . 7" FOR DX/RX gp D
vA vB C 3. DX MADE AND RX STARTED 6. REFERRAL REFUSED
§ REFERRED TO: TELEPHONE NUMBER
01 HISTORY and PHYSICAL EXAM w
02 DENTAL ASSESSMENT/REFERRAL REFERRED TO: TELEPHONE NUMBER
03 NUTRITIONAL ASSESSMENT
04 HS EouCATIoN COMMENTS/PROBLEMS
05 DEVELOPMENTAL ASSESSMENT IF A PROBLEM IS DIAGNOSED THIS VISIT, PLEASE ENTER
06 SNELLEN OR EQUIVALENT 06 YOUR DIAGNOSIS IN THIS AREA
07 AUDIOMETRIC 07
08 HEMOGLOBIN OR HEMATOCRIT 08
09 URINE DIPSTICK 09
10 COMPLETE URINALYSIS - 10
11 TB MULTIPUNCTURE 11
12 TB MANTOUX 12
CODE |_OMHERTESIS | SEE CODES ON REVERSE SIDE OF LAST PAGE [CODE | OTHER TESTS
A M HEIGHT WEIGHT 81000 PRESSURE HEAD START/
[] Ww : STATE PRESCHOOL
HCT. BIRTH WEIGHT Please enter values
Ha to the jst and provi
any information a
the child's health which H EAD STA RT
GIVEN TODAY NOT GIVEN TODAY | would effect s/her / STATE PRESCHOOL
NOW UP | STILLNOT | ALREADY | REFUSED [erticipagon in the ICD 9 CODES
DATE UP 10 uP 10 OR ad Start/State
IMMUNIZATIONS 0:08 DATE FOR | DATE FOR | COMTRA- | Preschool Program. 2 3
AGE AGE AGE INDICATED
A B C D :
31 POLIO - ORAL : 31 “THE QUESTIONS BELOW
33 MMR! MuR[]2 MR SER 3 1. Patient is Exposed to Passive (Second Yes] No[]]
38 Hib CV 38 : Hand) Tobacco Smoke.
2. Tobacco Used by Patient. Yes] No[]]
3. Counseled About/Referred For Yes[[] No[]
PATIENT VISIT (v) TYPE OF SCREEN (V) TOTAL FEES Tobacco Use Prevention/
Nea Fo) [3 woutine Visit i 5 Initial [Fanos Cessation.
PROVIDER OF SERVICE: Name, Address, PROVIDER uheeq Enrolled in WIC Referred to WIC
Telephone Number (Please Intlude Area Code) : NOTE: WIC requires Ht., Wt. and HGB/HCT
[3 PARTIAL SCREEN [13 SCREENING PROCEDURE RECHECK
ACCOMPANIES PRIOR PM 160 DATED | | | 5
i
PATIENT COUNTY AID IDENTIFICATION NUMBER
f ELIGIBILITY | | | | : | |
SITE OF SERVICE IF OTHER THAN ABOVE: Vv ousted sdk Lal enter Medi-Cal 1.0. number above AND attach P.O.E. laiei in
; This is to certify that the screening information is true and complete, and the results explained to VY Prtiont not on BeiCal snd has no other coverage for these services.
the child or his parent or guardian. | understand that payment and satisfaction of this claim may J j
be from Federal or State funds, and that any false cloims, statements or documents or conceal- If PM 160 Submitted for Information Only
ment of a material fact, may be prosecuted under applicable Federal or State law. | also certify | STATE PRESCHOOL PROJECT NUABER HEAD TAYE Granite
that none of the services billed on this form have been or will be billed to Medi-Cal, the ~, ™ J
patient, or other insurance providers. :
STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTIGN PRCGR/
Medi-Cal/CHC?
CONFIDENTIAL SCREENING/BILLING REPORT cov sou onencuoon —| Soro toss EAA tat; anes
“
OTHER tests: fDES ori IMMUNIZATIONS: CODES
13—Sickle Cell: Electrophoresis 34—Measles
T= Ta) oRlaPEP. ~ 35—Mumps
15—Lead: Blood Lead 36—Rubella
16—VDRL, RPR or ART 37—Hib
17—G.C. Culture 39—Polio: Inactivated
Poli i 18. Pan SHEE olio Vaccine (IPV)
19—PKU: Blood
20—Chlamydia Culture
21—Pelvic Examination
RELEASE OF INFORMATION NOTICE TO THE RESPONSIBLE PERSON:
The information provided on this form is voluntary and is used by the California Child Health and
Disability Prevention (CHDP) program in accordance with Article 7, Subchapter 13, Title 17 of the
California Administrative Code to monitor program quality, to reimburse providers of health
assessments for their services and to facilitate diagnosis and treatment at the local level for children
found to have health problems. Information provided may be transferred to local health departments
for follow-ups. Refusal to supply the information requested will hamper efforts to monitor this pro-
gram, may delay reimbursement procedures and may delay diagnosis and treatment of health
conditions affecting your child. For access to records containing this information you may contact the
individual listed below. You may aiso request the location of this information and the categories of
persons who use it.
Chief, Child Health and Disability Prevention Program
Family Health Division
714 P Street, Room 708
Sacramento, CA 95814
(916) 322-4780
x NOT STAPLE i A —————————
eb th eet pti. enh ms At +t Ev u——— [Se —— Ain, Nit Nii “i tt “kt cn tn niin
CLAIM CONTROL NUMBER FOR STATE USE ONLY
P [ PATIENT NAME (LAST) (FIRST) (INITIAL) MEDICAL RECORD NO. LA.
L Code Hr a a, mma on | eee T7894 02245350
$ BIRTHDATE AGE [SEX (arce)| PATIENT'S COUNTY OF RESIDENCE CODE TELEPHONE NUMBER NEXT VISIT 1-American Indian E| Mo Day Year Mo. Day Year 2-Asian
pl | | f | M2 | | Tome Fl) : RESPONSIBLE PERSON (NAME) (STREET) (cm ap) Code § Mex. Amer./Hispa
-Whit
N in 7-Other
I . Pacific Islander
REFUSED PROBLEM SUSPECTED DATE OF SERVICE v5 wh ing
MENT Jo [ve Ero * 1 1. NO DX/RX INDICA
Indicate outcome for each SUSPECTED NEW | KNOWN gy 10NABL
screening procedure NEEDED c 0 FEES - 2 Son LED 3 RE s A orcs EVANS vA vB " 3. DX MADE AND RX STARTED 6. REFERRAL REFUSED =
REFERRED TO: TELEPHONE NUMBER
01 HISTORY and PHYSICAL EXAM
02 DENTAL ASSESSMENT /REFERRAL REFERRED TO: TELEPHONE NUMBER
03 NUTRITIONAL ASSESSMENT
ANTICIPATORY GUIDANCE
04 HATH EDUCATION COMMENTS/PROBLEMS
05 DEVELOPMENTAL ASSESSMENT IF A PROBLEM IS DIAGNOSED THIS VISIT, PLEASE ENTER
06 SNELLEN OR EQUIVALENT 06 YOUR DIAGNOSIS IN THIS AREA
07 AUDIOMETRIC 07
08 HEMOGLOBIN OR HEMATOCRIT 08
09 URINE DIPSTICK 09
10 COMPLETE URINALYSIS 10
11 TB MULTIPUNCTURE 11
12 TB MANTOUX 12
Coo | OTHERTESTS | SEE CODES ON REVERSE SIDE OF LAST PAGE | CODE| OTHER TESTS
A M HEIGHT WEIGHT BLOOD PRESSURE
HGB “HCT. BIRTH WEIGHT
GIVEN TODAY NOT GIVEN TODAY
Too STL Nor ALREADY REFUSED ICD 9 CODES
IMMUNIZATIONS FOR DATE FOR | DATE FOR CONTRA- 1 2 | | 3
AGE AGE AGE INDICATED >
A B ¢ D adn Popp sg $ E33
31 POLIO - ORAL : 3 THE QUESTIONS BELOW
32 DPT Dt/Td 2 MUST BE ANSWERED
33MMR[}! MuR[ PR MR[P 3 1. Patient is Exposed to Passive (Second ~~ Yes[] No[]
38 Hib CV 38 Hand) Tobacco Smoke.
2. Tobacco Used by Patient. Yes[[] No[]
3. Counseled About/Referred For Yes[[] No[]
PATIENT VISIT (v) TYPE OF SCREEN (v/) TOTAL FEES Tobacco Use Prevention/
-New Patient or
Extended Visit | [ Foute Visit [1 Initial | [ Frerode
Cessation.
PROVIDER OF SERVICE: Name, Address,
Telephone Number (Please Include Area Code) } \
PROVIDER NUMBER
Enrolled in WIC Referred to WIC
NOTE: WIC requires Ht., Wt. and HGB/HCT
SITE OF SERVICE IF OTHER THAN ABOVE:
[] PARTIAL SCREEN [3 SCREENING PROCEDURE RECHECK
ACCOMPANIES PRIOR PM 160 DATED L i ! i |
This is fo certify that the screening information is true and complete, and the results explained to
the child or his parent or guardian. | understand that payment and satisfaction of this claim may
be from Federal or State funds, and that any false claims, statements or documents or conceal-
ment of a material fact, may be prosecuted under applicable Federal or State law. I also certify
thot none of the services billed on this form have been or will be billed to Medi-Cal, the
patient, or other insurance providers.
E
PATIENT
ELIGIBILITY | |
COUNTY AID IDENTIFICATION NUMBER
wl Hw TR Rae gD
If covered by Medi-Cal, enter Medi-Cal 1.D. number above AND attach P.0.E. label in
shaded area below.
Patient not on Medi-Cal Parent Fp has. read d and sgted eligibility statement.
v
Vv
Av. |
SIGNATURE OF PROVIDER DATE
CONFIDENTIAL SCREENING/BILLING REPORT
STATE OF CALIFORNIA-CHILD HEALTH AND DISABILITY PREVENTION PROGRAI
COPY 1 - MAIL TO MEDI-CAL CHDP pi
Medi-Cal/CHDP
P.O. Box 15300
Sacramento, CA 95851-1300
PMEN 7 5
tus em am. - - -- ——— ew «ae p 3 v
' itl WRAL 3 vy Aa if a 78 :
OTHER TESTS: CODES OTHER IMMUNIZATIONS: CODES
13—Sickle Cell: Electrophoresis oa 34—Measles : go
T4-S(edd FERS. vo, B-Mumps
~15=lend:iBloodtead> ~~ 36—Rubella -
VE-VORL, RPRor ARTE iil ip 0 Web, :
17—G. C. Culture rea ; & 39 Polio: Pl ivated
18 Pap. Srriear..
19—PKU: Blood ile . : - Lp i
20—Chlamydia Culture : ee : ma i
: Polio Vaccine (PV)
21—Pelvic Examination be ml ea fae “ 0
RELEASE OF INFORMATION NOTICE TO THE RESPONSIBLE PERSON:
The information provided on this form is voluntary and is used by the California Child Health and
Disability Prevention (CHDP) program in accordance with Article 7, Subchapter 13, Title 17 of the
California Administrative Code to monitor program quality, to reimburse providers of health
assessments for their services and to facilitate diagnosis and treatment at the local level for children
found to have heaith problems. information provided may be transferred to local health departments
for follow-ups. Refusal to supply the information requested will hamper efforts to monitor this pro-
gram, may delay reimbursement procedures and may delay diagnosis and treatment of health
conditions affecting your child. For access to records containing this information you may contact the
individual listed below. You may also request the location of this information and the categories of
persons who use it.
Chief, Child Health and Disability Prevention Program
Family Health Division : Ts vive
714 P Street, Room 708 sires :
Sacramento, CA 95814
(916) 322-4780