CHDP Claim Questions

History

History and Physical Exam

Please enter history and physical exam result code

Please enter history and physical exam fee

Dental

Dental Assessment/Referral

Please enter dental assessment result code

Nutr

Nutritional Assessment

Please enter nutritional assessment result code

AGHE

Anticipatory Guidance Health Education

Please enter antic. guidance health dev result code

Develop

Developmental Assessment

Please enter developmental assessment result code

Snellen

Snellen or Equivalent

Please enter Snellen or equivalent result code

Please enter Snellen or equivalent fee

Audio

Audio metric

Please enter audio metric result code

Please enter audio metric fee

Hemo

Hemoglobin or Hematocrit

Please enter hemoglobin or hematocrit result code

Please enter hemoglobin or hematocrit fee

TB Mp 11

Tb Multipuncture

Please enter Tb Multipuncture result code

Please enter Tb Multipuncture fee

TB Mx 12

Tb Mantoux

Please enter Tb Mantoux result code

Please enter Tb Mantoux fee

The following screens apply to OtTst 13, 14, and 15

Other Tests

1 Sickle Cell (13)

2 Lead:FEP (14)

3 Lead:Blood (15)

4 VDRL/RPR/ART (16)

5 G.C. Culture (17)

6 Pap Smear (18)

7 PKU:Blood (19)

8 Chlamydia (20)

9 Pelvic Exam (21)

B Leave Blank

Result codes

A No Problem Suspected

B Refused or Not needed

C New Problem Suspected

D Known Problem

E Leave Blank

HGB 28

Hemoglobin

Please enter patient's hemoglobin

HCT 29

Hematocrit

Please enter patient's hematocrit

Units

<A>=Inch, Pound, Ounce Unit

<M>=Metric Unit

Please enter <A>=inch, pound, ounce unit <M>=metric units

Height

Height

Please enter patient's height

Weight

Weight

Please enter patient's weight

HistAmt

SnelAmt

AudiAmt

HemoAmt

UrdpAmt

UrcpAmt

TBmpAmt

TBmxAmt

DtServ

Date of Service

Please enter date of service

DtNxVisit

Next Visit

Please enter date of next visit

Polio

Immunization Results

A Given today/Up to date

B Given today/Not up to date

C Not given today/Up to date

D Refused or contra-indicated

E Leave Blank - No Answer

Please enter POLIO immunization status <A>,<B>,<C>,<D>, or <E>.

PoliAmt

DPT

Diphtheria, pertussis, tetanus

Immunization Results

A Given today/Up to date

B Given today/Not up to date

C Not given today/Up to date

D Refused or contra-indicated

E Leave Blank - No Answer

Please enter DPT immunization status <A>,<B>,<C>,<D>, or <E>.

DptiAmt

Cnty

County

Please enter patient's county of residence

CntyCode

AidCode

L.A. Code

L.A. Code

Please enter L.A. code

EthCode

Ethnic Code

Please enter patient's ethnic code

Ethnic Codes

1 Am. Indian

2 Asian

3 Black

4 Filipino

5 Hispanic

6 White

7 Other

8 Pacific Is

9 Leave Blank

HibImm

Immunization Results

A Given today/Up to date

B Given today/Not up to date

C Not given today/Up to date

D Refused or contra-indicated

E Leave Blank - No Answer

Please enter Hib Cv immunization status <A>,<B>,<C>,<D>, or <E>.

HibiAmt

Mtpi

MtpiCode

MtpiAmt

B/P

Blood Pressure

Please enter patient's blood pressure

Urdip

Urine Dipstick

Please enter urine dipstick result code

Please enter urine dipstick fee

Urcmp

Complete Urinalysis

Please enter complete urinalysis result code

Please enter complete urinalysis fee

BtWt

Birth Weight

Please enter patient's birth weight

Vstp

Sctp

TobPassSmk

Patient Exposed to Passive Smoke

Please enter Y/N is patient exposed to tobacco smoke?

TobUsed

Tobacco used by Patient

Please enter Y/N does the patient use tobacco?

TobConsl

Counseled About Tobacco Prevention?

Please enter Y/N was the patient referred for tobacco use counseling?

WIC

Please enter Y/N - was patient enrolled in WIC?

Mccv

ReChkDt

Screening Procedure Recheck

Please enter procedure recheck date

RchkDt

Dx1

Dx2

Dx3

Diagnosis Code

Please enter diagnosis code

Ott1, Ott1 Code, Ott1Amt

Other Immunization #1 Code

Immunization Type

1 Measles (34)

2 Mumps (35)

3 Rubella (36)

4 Hib (37)

5 Polio (IPV) (39)

6 Leave Blank - No answer

Please enter other immunization #1 code

Please enter the fee.

OtOtt2, Ott2 Code, Ott2Amt

Other Immunization #2 Code

Immunization Type

1 Measles (34)

2 Mumps (35)

3 Rubella (36)

4 Hib (37)

5 Polio (IPV) (39)

6 Leave Blank - No answer

Please enter other immunization #2 code

Please enter the fee.

Ott3, Ott3 Code, Ott3Amt

Other Immunization #3 Code

Immunization Type

1 Measles (34)

2 Mumps (35)

3 Rubella (36)

4 Hib (37)

5 Polio (IPV) (39)

6 Leave Blank - No answer

Please enter other immunization #3 code

Please enter the fee.

Oti1, Oti1 Code, Oti1Amt

Other Test #1

Please enter the number of the other test #1

Please enter the other test #1 result code

Please enter the other test #1 fee

Oti2, Oti2 Code, Oti2Amt

Other Test #2

Please enter the number of the other test #2

Please enter the other test #2 result code

Please enter the other test #2 fee

Oti3, Oti3 Code, Oti3Amt

Other Test #3

Please enter the number of the other test #3

Please enter the other test #3 result code

Please enter the other test #3 fee

InScr 39

Initial Screen

Please enter Y/N was this an initial screen?

PtlSc 45

Partial Screen

Please enter Y/N is this a partial screen?

Mcal 47

Covered by Medicaid

Please enter Y/N Is patient covered by Medi-Cal?

MMR 33

Measles, mumps, rubella

Immunization Results

A Given today/Up to date

B Given today/Not up to date

C Not given today/Up to date

D Refused or contra-indicated

E Leave Blank - No Answer

Please enter MMR/MuR/MB immunization status <A>,<B>,<C>,<D>, or <E>

Please enter the fee.

Immunization Type

1 MMR (measles/mumps/rubella)

2 MuR (mumps/rubella

3 MR (measles/rubella)

4 Leave Blank - No answer

Please enter MMR/MuR/MB immunization type 1,2,3,4.

Immunization Results

A Given today/Up to date

B Given today/Not up to date

C Not given today/Up to date

D Refused or contra-indicated

E Leave Blank - No Answer

RefTo 21

Referred to (first)

Please enter (first) person referred to

RefTo 22

Referred to (second)

Please enter (second) person referred to

Cmmts 23

Comments

A pop-up screen will appear which is labeled Enter Comments/Problems

Press [ESC] to quit without saving

Press [CTRL+W] to save your notes

NewPt 38

New Patient

Please enter Y/N was this a new patient or an extended visit?