HEALTH CHECK PROGRAM GUIDE WEBINAR Q&A DOCUMENT

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1 Question History/Physica l Exam Components If a parent notes on the initial history form that the child has or had a medical condition (ex. Eczema), can we enter this in their medical history without having to obtain the records to support it? We often do this and enter who follows them, what medicines are used, past history, etc. Sometimes we even put per parent. Answer Yes, you will need to capture the client s medical history and noting per parent is appropriate. As a CHERRN, you would not be able to use the eczema diagnosis code unless you have either past medical records to support the diagnosis was made by a previous provider or if the client has a previous diagnosis of eczema documented in the medical record by an advance practice provider/ physician at your agency. Does anyone have the Initial History Questionnaire "embedded" into their EHR where it can be edited and updated as needed, as opposed to just filling it out and scanning into the chart? I have recently had some teens that refuse the genital portion Yes, many agencies have built the Bright Futures Initial History into the agency s electronic health record (EHR). The initial history is required to be documented in the EHR. Agencies are responsible for developing a system for providers to be able to show that they have reviewed and updated the initial history at each subsequent well child preventative visit. The documentation should include any updates to the client s past medical history, family history and the date(s) each section of history was updated/reviewed by the agency provider. Any updates to the initial history must be located in one place so that providers can easily review the complete and most current client history. If the agency chooses to pull the history forward into each consecutive visit (to ensure providers are reviewing history) then any updates to the history must also carry forward to each subsequent visit note. Please note that social and education history are not included in the initial history or its updates but are required to be included and updated as part of each well visit. This should be a rare occurrence if the provider explains the need to examine all parts of the teen to make sure the teen is healthy. It is also important to always use a chaperone with males and females for at least the genital part of the exam. If after a discussion the teen or child still refuses, the provider should document that

2 of the physical exam. What do I need to document when this occurs? Interperiodic Screenings Interperiodic screenings would also include for the visits required for foster children? the child refused that portion of the exam, the reason for the deferral, and the plan to examine that portion at another visit (if another visit is planned). Children in foster care should be seen within the first 7 days of placement in care and ideally within 72 hours for an initial acute health screening visit. A comprehensive well child visit should be provided within 30 days of placement. After that time children in foster care should be seen in 60 days and then follow an enhanced health care schedule for follow up well child visits because of the high prevalence of health care problems and multiple transitions: Monthly for infants from birth to age 6 months Every 3 months for children age 6 to 24 months Twice a year for children and teens between 24 months and 21 years of age ( C7C0-41EE FD0AA4F2/AAP_Standards_of_Care.pdf) Foster Care Visit Options and Code guidance is available from Fostering Health NC for the different types of visits (acute visit, comprehensive health visit, and follow up well child visits) at: ym.com/resource/collection/ac86eda7-3cdf-4db7-ab8f- 277E59FE5A67/Framework_for_Foster_Care_Visits_ pdf Hearing Screening Can we do hearing on every patient 4 and up at every checkup including teens and it still be covered by insurance? We should add hearing frequencies 6000 hz and 8000 hz for Yes, but remember that hearing and vision screenings are considered part of the bundled well visit service for Medicaid and therefore, agencies are not reimbursed separately for the hearing screening with Medicaid. However, it is fine to provide a hearing (and vision) screening at every well child visit to ensure that agency staff do not miss completing the appropriate hearing and/or vision screening when required. It is not clear that all private insurers will reimburse agencies for the vision screening if it is done at a visit that is not required by Bright Futures since Bright Futures represents the services required to be covered in pediatric care by the Affordable Care Act. This follows Best Practice Recommendations per the 2017 Bright Futures Periodicity schedule. This Best Practice Recommendation is listed below and is Footnote #10 on the 2017 BF Periodicity Schedule. This is a recommendation, and not a requirement of the HCPG.

3 hearing screening of children 11 years of age and older? Vision Screening Can we do vision on every patient 3 and up at every checkup including teens and it still be covered by insurance? We use for vision screenings (Snellen, Sure sight). We have a new Vision Spot Screener that is approved for use through adulthood; can this instrument be used >5 years old? Should it be billed as 99177? Screen with audiometry including 6,000 and 8,000 Hz high frequencies once between 11 and 14 years, once between 15 and 17 years, and once between 18 and 21 years. See The Sensitivity of Adolescent Hearing Screens Significantly Improves by Adding High Frequencies ( Yes, you can complete vision screening on every patient three years and up including teens. However, remember that hearing and vision screenings are considered part of the bundled well visit service for Medicaid and therefore, agencies are not reimbursed separately for the hearing screening with Medicaid. However, it is fine to provide a hearing (and vision) screening at every well child visit to ensure that agency staff do not miss completing the appropriate hearing and/or vision screening when required. It is not clear that private insurers will reimburse agencies for the vision screening if it is done at a visit that is not required by Bright Futures since Bright Futures represents the services required to be covered in pediatric care by the Affordable Care Act. Per the current HCPG on page 15 - According to the AAP policy statement published in January 2016, instrument-based screening devices can be used at any age but have better success after 18 months of age. The AAP Bright Futures Guidelines states that instrument-based ocular screening may be used to assess risk at ages 12 and 24 months, in addition to the well visits at 3 years through 5 years of age. Best Practice is to use an objective screening such as the HOTV or Snellen vision screening charts first for children greater than 5 years of age. If the provider experienced difficulty performing an objective vision screening (i.e. had a child that was uncooperative) then the provider would use the instrument-based screening device to complete the vision screening. Although Best Practice guidance has been provided above, the instrument-based screening devices can be used at any age. If an agency completed the vision screening for clients greater than 5 years of age using an instrument-based screening device, this screening would meet the vision screening required component of the HCPG. Per CMS, CPT code is to be used (instrument-based ocular screening, bilateral with onsite analysis) and no additional reimbursement is allowed for this code. Refer to page 15 of the current HCPG. BMI Do you consider a BMI over 85 an abnormal finding? Yes, a BMI less than the 5 th percentile and a BMI greater than the 85 th percentile are both considered abnormal objective findings. An appropriate plan of care would need to be documented to address the finding.

4 If BMI is the only thing abnormal, do we still use Z00.121? Nutritional Assessment What do we do for nutritional referral when they do not qualify for WIC and are not eligible for Medicaid and they need to have further nutritional education. Oral Health Screening How is the provider supposed to do a risk assessment in the event that a child does not have a dental home? Yes, because the abnormal BMI is an abnormal objective finding and will require the provider to develop a plan of care to address that concern. It does not mean that the provider is required to make a referral, but the provider should develop an appropriate plan of care for follow-up which at times could include a referral. The Z is not always going to lead to a referral but does need to be used for any abnormal findings. Medicaid is using that code as a proxy for referrals but it is not totally going to match. Contact your local hospital, community health center, or physician practice to see if one of those locations provide nutrition counseling. If so, verify that the location can set up payment plans for the client to receive nutrition counseling from a registered nutritionist. You may also want to contact your county Cooperative Extension agency to see for help accessing resources. Several counties have Expanded Food and Nutrition and Education Programs (EFNEP) which can be found at: The Bright Futures Nutrition Manual includes strategies for Health Professionals to promote healthy eating behaviors. HCPG requires an Oral Health Screening at every preventive health visit. This means that a physical assessment of the mouth and teeth must occur (is required) at every Health Check visit. According to the HCPG, an oral health risk assessment is recommended for all young children at well-child visits up to age 3 ½ years. However, questions about risk and need for fluoride supplementation are required by the HCPG at several ages. LHDs are required to use the Bright Futures Pre-Visit Questionnaires (from 2009) and these contain a minimum set of oral health risk questions. However, these forms are outdated and do not have all of the questions needed which are based on the most current (2017) Bright Futures recommendations. The forms are being updated by the AAP.

5 The current oral health questions included in the required BF Pre-visit Questionnaires for the 6 and 9-month old visits ask about risks which include a family history of caries, child sleeping with a bottle and if the child continuously breastfeeds at night. Even if the answer to one or more of these questions is yes, that does not automatically require a referral to a dentist. ERRN needs to assess need for referral to a dentist based on findings from the history and exam (e.g., acute dental issue on exam). Additional questions asking about the risk and need for fluoride supplementation (i.e. no primary water source with fluoride) are required by the HCPG at the 6 and 9-month old visits. LHDs may need to understand how to get well or bottled water tested and if there is a need for standing orders for fluoride supplementation when needed based on the fluoride levels in the report. LHDs must be able to test and verify or report fluoride levels in the water. The Pre-Visit Questionnaires have appropriate oral health questions for the 12, 18, 24 and 30-month old visits and for the 3 and 6-year visits. These include two questions: the presence of a dental home and if child s primary water source has fluoride. Additionally, these two questions are required to be asked at the 4 and 5- year visits and then at every subsequent visit up to 16 years because this is required by the HCPG (assessment for dental home and for risk and need of fluoride) All children 3 years and older are required to be assessed for the presence of a dental home. However, as mentioned earlier, the pre-visit questionnaire is required for use by LHDs and asks about dental home starting at 12 months and a risk assessment must be done to determine need for referral to dental home earlier. Remember, when any screening indicates a need for dental services or a referral to a dental home (at any age), referrals are required by the HCPG for needed dental services (which may be a referral for a dental home because the child does not have one) and documented in the child s medical record; OR An explanation for why a referral to a dentist or dental home is not able to be made and a plan of care to address any acute issues. Regarding referral to a dental home, is it okay to document Yes, that would be appropriate to document all of this (patient does not have dentist, local dental provider list given, and encouraged family to schedule an appointment) in situations where the child does not have a dental home. It would be ideal to have the local dental provider list include information about which dentists accept Medicaid, and offer services in Spanish.

6 patient does not have a dentist, local dental provider list given, and encouraged family to schedule appt? When documenting that we referred patient to dental, do we not need to follow-up since we didn't do a referral? The Bright Futures Pre-Visit questions required for use by LHDs begin to ask about a dental home at the 12 months visit. Anticipatory guidance must be provided and documented about proper brushing with fluoride toothpaste (amount depends on age). Fluoride varnish is recommended to be offered but is not required if they have teeth and it is due. Fluoride dental varnish procedures can be provided once every 60 days for a total of six times from tooth eruption until 3 ½ years of age (42 months). Please refer to the Into the Mouths of Babes, Oral Health Section website for additional guidance which is located at the following link: Also, refer to the NC DMA Clinical Coverage Policy for Physician Fluoride Varnish Services dated October 1, 2015 for additional guidance. When any screening indicates a need for dental services, referrals must be made (are required by the HCPG) for needed dental services and documented in the child s medical record OR an explanation for why a referral to a dentist is not able to be made and a plan of care to address any acute issues. For the referrals, at ages 0-3 at the last webinar it was stated that documenting that we verbally referred the parent and gave them a list of local pediatric dentists. Is this still true for this age group as well? Other When referring a client to establish routine dental care, the provider will follow the guidance listed above. There is no need to track dental referrals for establishing routine dental care. However, the referral needs to be clearly documented in the client s chart. If the client has an abnormal acute finding that warrants a dental referral ), the provider is responsible for tracking/follow-up regarding the referral to dental related to abnormal finding to assure that the patient secures care for the acute problem. Yes, this is still correct. Please see the details about the guidance given above. However, when there is an acute problem in any age child, an appointment needs to be scheduled and there must be follow up to make sure the patient keeping that appointment to secure appropriate care. Commented [GM1]: We should remove this language.

7 than if a problem of course. What if they say they can't afford the referral and do not qualify for Medicaid? Even if there are no abnormal findings, but we are making a referral to establish dental care, we need to use Z00.121? Can you clarify what are dental risk assessments? Is there a specific tool or just the BF screening questions? Need more information about dental health form that can be completed for Bright Futures. This response is regarding a dental referral. Several health departments do offer sliding fee scale services for dental care. If your LHD does not offer those services, your LHD should research for any options in neighboring counties for dental services such as at a Federally Qualified Health Center (FQHC). Providers do not need to use Z when there are no abnormal findings and the referral is to establish a dental home. Screening questions are required as part of the oral health package when billing for the risk assessment and fluoride varnish for those clients under 3.5 years. This is included as part of the training for Into the Mouths of Babes. However, there are also required general dental risk assessments required even when not providing the oral health package. LHDs are required to use the Bright Futures Pre-Visit Questionnaires (from 2009) and these contain a minimum set of oral health risk questions. However, these forms are outdated and do not have all of the questions needed which are based on the most current (2017) Bright Futures recommendations. The forms are being updated by the AAP. The current oral health questions included in the required BF Pre-visit Questionnaires for the 6 and 9-month old visits ask about risks which include a family history of caries, child sleeping with a bottle and if the child continuously breastfeeds at night. Even if the answer to one or more of these questions is yes, that does not automatically require a referral to a dentist. ERRN needs to assess need for referral to a dentist based on findings from the history and exam (e.g., acute dental issue on exam). Additional questions asking about the risk and need for fluoride supplementation (i.e. no primary water source with fluoride) are required by the HCPG at the 6 and 9-month old visits. LHDs may need to understand how to get well or bottled water tested and if there is a need for standing orders for fluoride supplementation when needed based on the fluoride levels in the report. LHDs must be able to test and verify or report fluoride levels in the water. The Pre-Visit Questionnaires have appropriate oral health questions for the 12, 18, 24 and 30-month old visits and for the 3 and 6-year visits. These include two

8 questions: the presence of a dental home and if child s primary water source has fluoride. Additionally, these two questions are required to be asked at the 4 and 5- year visits and then at every subsequent visit up to 16 years because this is required by the HCPG (assessment for dental home and for risk and need of fluoride) All children 3 years and older are required to be assessed for the presence of a dental home. However, as mentioned earlier, the pre-visit questionnaire is required for use by LHDs and asks about dental home starting at 12 months and a risk assessment must be done to determine need for referral to dental home earlier. Remember, when any screening indicates a need for dental services or a referral to a dental home (at any age), referrals are required by the HCPG for needed dental services (which may be a referral for a dental home because the child does not have one) and documented in the child s medical record; OR An explanation for why a referral to a dentist or dental home is not able to be made and a plan of care to address any acute issues. Per the current HCPG, there are recommended (not required) more comprehensive oral risk screening tools which include either the NC Priority Oral Risk and Referral Tool (PORRT) which can be found at: 0PORRT_form.pdf; and referral guidelines at: 0Referral%20Guidlines.pdf Can we charge for oral evaluation D0145 even if they don't have teeth yet? There is also the Bright Futures Oral Health Risk Tool which includes guidelines for referral at: No, this cannot be billed by itself for an oral evaluation. D0145 (by non-dentists) must be billed along with D1206 when topical fluoride varnish is completed and requires that the child have teeth. HCPG requires an Oral Health Screening at every preventive health visit. This means that a physical assessment of the mouth and teeth must occur (is required) at every Health Check visit. This is considered part of the physical exam, so you do not bill additionally for the assessment of the mouth and teeth.

9 Infants and young children are recommended but not required to receive dental varnishing from the time of tooth eruption to age 3 ½ years (up to 6 oral screening packages) Do we code for oral evaluation D0120 if they are > 3.5 years old? Providers may bill for both the well visit and the oral screening package on the same day. No, D0210 is only use by dental providers. The oral evaluation that you provide as part of the well visit is included as part of the well visit and is not a separately billable service. There are limited billable oral screening services that can be provided in health departments and practices that see children and these are defined in the oral screening package. The oral screening package can only be provided and billed up to 3.5 years of age and consists of an oral screening examination, preventive oral health and dietary counseling and application of fluoride varnish as per NC Medicaid Clinical Coverage Policy #1A-23 Physician Fluoride Varnish Services. Bill CPT D1206 topical fluoride, then CPT D0145 oral evaluation Smoking Cessation Screening/Alco hol and/or substance abuse structured Screening To clarify, can CHERRNs provide the counseling for & (Smoking Cessation Screens/Interve ntion) and & (Alcohol and/or substance abuse structured screening and brief intervention) or medical providers only? The CPT codes for and are regarding tobacco cessation and counseling. This requires that the CHERRN have training and skills in tobacco cessation for the patient such as use of the 5A s or CEASE. There are also time limits based on these codes, so time should be documented. These codes are within the scope of the CHERRN if they have the skills and knowledge. The same applies to alcohol and/or substance abuse structured screening and brief intervention and referral for treatment. The CHERRN needs to have received the training and must have the knowledge and skills to be able to provide a brief intervention (time based on code in minutes) which includes counseling and referral for treatment as appropriate. The CHERRN should only provide and bill for and if they are comfortable with their ability to provide this service. It is recommended that you talk with your supervising medical provider about the skills and knowledge that the CHERRN needs to bill for and There is also a webinar about the use of the CRAFFT and screening brief intervention, referral and treatment on the Child Health Provider Resource Page.

10 Risk Assessments There seems to be quite a few changes regarding risk assessments that are not yet reflected on the pre-visit questionnaires. Do you have any recommendatio ns as to how to capture all of these until the new questionnaires are released? We will schedule webinars to try to highlight the changes regarding risk assessments. Plan of Care We send records to the PCP after every visit we complete. This is stated in our policy. Does this also need to be noted in the chart that we do so? Billing & Coding I am not truly understanding the z codes that we are needing to do. If we only see clients in the health dept. that do not have any disease process for well child exams, do we need to have We would recommend that you document in the patient s chart that the records have been sent to the PCP to assure appropriate follow-up and reflect continuity of care. Yes: Z Encounter for routine child health examination with abnormal findings. This code is to be used when abnormal findings are present for the date of service the client is seen. Z Encounter for routine child health examination without abnormal findings. If a client has a history of a disease or illness but no abnormal findings are present during the visit, then the appropriate code to use would be Z along with an appropriate personal history of Z-code if pertinent.

11 any other z codes besides Z or Z00.129? Can you explain more about what a personal history z-code is and when to use? CHERRNs should use ICD-10 code ranges from Z00-Z99; Z77-Z99; or Z87 when reporting a disease or condition that the parent or guardian or client reports without a documented diagnosis from a higher-level provider (either in the client s medical record at the agency or by obtaining past medical records) Z00-Z99 Factors influencing health status and contact with health services Z77-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status Z87- Personal history of other diseases and conditions Local Health Department CH Clinical staff could search the agency s top 10 most frequently used diagnosis codes encountered by CHERRNs and providers. To clarify if the client has been previously diagnosed with an illness but is not present on exam it would require a Z code of Z If present, then a Z code of Z with a referral. CHERRNs can meet with the agency s medical provider to assist with developing a help guide/cheat sheet of appropriate Z-codes for the CHERRNs to utilize. A review of the Z code section is a good place to start for the CHERRNs since it is the ICD-10 equivalent to the V code section for the previous ICD-9 codes. Providers must indicate referrals using Z Encounter for routine child health examination with abnormal findings, along with the diagnosis code attributed to the finding to ensure proper tracking of referrals. Is the Z23 ICD- 10 code still required if the patient is being seen for a WCC? Are we supposed to still be using SL modifier when billing state supplied vaccines? Modifier 25: in reading, it says Yes, providers must use ICD 10-CM coding for all immunizations given after October 1, In all routine cases, that code is Z23. Refer to Section V: Immunizations of the current HCPG regarding billing & coding guidance for immunizations. This guidance is located on pages of the current HCPG. Please consult with your regional immunization consultant or PHNPDU consultant for further questions about billing for immunizations. Per CCI: When claiming an immunization administration with a preventative service visit, the 25 modifier must accompany the E/M code. Refer to page 60 of

12 it must be used for a separate service. Can it be billed for a preventative visit code along with immunizations for an ERRN visit? We think of the immunizations as being a part of the well child visit and not as a separate service How do you code a well and a sick visit for a child? If you do a Sick and a Well visit on the same day on a child do you create 2 different encounters or do you code on one encounter? How do you code a well child visit if patient is also being seen in Women s Health clinic for their annual exam? the current HCPG. Please contact your regional immunization or PHNPDU consultant for further questions about immunizations. This guidance is found in the current Health Check Program Guide on pages There were several counties who have been successful with coding for these and we suggest consulting with Rockingham, Wilkes, Harnett, Montgomery and others. Documentation is key, and it is best to learn from those who have been successful. Montgomery shared that they create a Primary Care note for the sick visit (done by the advanced practice provider or MD) as well as a WCC visit (done by the CHERRN) on the same day. Other health departments have done this differently. Refer to pages of the current HCPG. When Medicaid beneficiaries under 21 years of age receiving a preventative visit also require evaluation and management of a focused complaint, the provider may deliver all medically necessary care and submit a claim for both the preventative service and the appropriate level of focused, E/M service. Provider documentation must support billing of both services. Providers may create separate notes for each service render to document medical necessity. If the provider creates one document for both services, he or she must clearly delineate the problem-oriented history, exam, and decision making from those of the preventative service. Please see the previous question and response for guidance about consulting with other LHDs who have been billing for sick and well visits on the same day. Refer to the Documentation, Coding, Billing Guidance Document, Version 8 which is located at the DPH website for Local Health Departments at the following link: CodingandBillingGuidanceDocument.pdf. How to bill when Child Health and Family Planning services interface:

13 If the reason for visit is for a well child exam but the client presents also wanting FP services, the visit is billed as follows: a. Bill the Well Child Exam along with all required components under the CH program type. The CH portion of the visit would be documented using the CH templates whether in EHR or paper format. b. REPORT all the FP portions of the visit, assuring that all required FP components have been completed. The FP portion of the visit would be documented using the FP templates whether in EHR or paper format. c. To offer 340B medications, the visit must be documented separately so that it is clear a FP visit has been made therefore establishing the client in FP. d. Document using a separate encounter form. If the reason for visit is for FP services but the client is also in need of their CH visit, the visit is billed as follows: f. REPORT the Well Child Exam along with all required components under the CH program type. The CH portion of the visit would be documented using the CH templates whether in EHR or paper format. g. Bill all the FP portions of the visit, assuring that all required FP components have been completed. The FP portion of the visit would be documented using the FP templates whether in EHR or paper format. h. To offer 340B medications, the visit must be documented separately so that it is clear a FP visit has been made therefore establishing the client in FP. i. Document using a separate encounter form. General Reminders 340B drug eligibility requires that the client be a registered FP client. If a client is seen for FP services, all the assessments and education are completed and separately documented (separate from the CH documentation) and an encounter reflects that the client received FP services, then the client should be able to receive 340B drugs, even if the encounter is entered as report only. Assure all CH service components are provided. DO NOT try to document both visits on the same program template. Neither the CH or FP templates are structured to comply with both program requirements. The following information must be shared related to the provision of family planning services during a Health Check or Child Health visit: 1. General information that includes the health benefits of abstinence, and the risks and benefits of all contraceptive options; 2. Specific information related to the adolescent s contraceptive choice including effective use, benefits, and efficacy of the method, and possible side effects or complications;

14 3. Benefits of dual-method use (for example, condoms for STI prevention and a second method of contraception); 4. How to discontinue the method selected and information on backup methods and emergency contraception; CBGD PHNPDU , v Emergency 24-hour number and location where emergency services can be obtained; 6. At subsequent visits, review this information with the recipient. Additional HCPG Questions Will the new Bright Futures include the ACE questions? Request for Past Medical Records What is the max time you recommend we wait for past medical records from a previous provider in relation to billing? CH Program/CH 351 AA Why is it mandatory for one person to be on the live webinar? It is very hard to do that when we are very short staffed in our agency right now. We do not think the new Bright Futures forms will include the ACE questions, but we think there will be more questions about social determinants of health. The new forms should come out in the next several months but that is an effort outside of our control with the American Academy of Pediatrics, which is a national organization. Per Public Health Nurse & Professional Development Unit, it is not recommended to hold billing to obtain medical records from another provider. The provider seeing the client should provide all the required components. The only thing that the provider would not have is the "reviewed other medical records". That may contribute to the level of service, but the provider/agency could always go back and revise the billing if needed. This is a specific requirement signed off on as part of your agency s Child Health 351 Agreement Addenda: Ensure participation by at least one Child Health Program manager or staff member to attend C&Y Branch-supported child health meetings for programmatic updates and service information, whether the Local Health Department provides or assures direct health care services. Information shall be disseminated to all Child Health Program staff at the Local Health Department. Activity 351 Child Health funds may be used to support attendance at programmatic updates.

15 Foster Care Physicals I thought CHERRN s could not see Foster children. CHERRNs cannot see children in foster care for the acute first visit within the first seven days. The initial visit is an evaluation/management visit for the provider to evaluate the client and address any emergent issues as well as prescribe any needed medications. The provider will obtain a medical release of information to request previous medical records. The provider will schedule a well child preventative visit to be completed within 30 days of the initial visit. This allows the provider time to obtain and review the client s previous medical records prior to the scheduled preventative visit. If an advanced practice provider or MD determines after the first well child preventative visit or after a couple of well child preventative visits that the child in foster care does not appear to have any acute issues, that provider can allow a CHERRN to provide the well child preventative for that foster care child. It is up to the decision of the supervising provider whether he or she thinks an CHERRN would be able to see that child. Of course, the CHERRN should consult with the supervising provider with any concerns as they occur. If a child is in foster care, diagnosis code Z62.2, does that entail Z00.121? If there are any issues of concern (abnormal objective or subjective findings) for a child in foster care, the Z should be used, regardless of whether a referral is made or not.