HOW TO COMPLETE A 360 COMPREHENSIVE EXAM

HOW TO COMPLETE A 360 COMPREHENSIVE EXAM

A page by page guide for 2018

Overview The 360 Comprehensive Exam must be completed during a single face-to-face encounter and completed by an acceptable health care professional (MD, DO, PA, NP). The only attachments allowed are the medication list and depression screening supplements (PHQ 9, standard screening tool and/or clinical interview) Clinicians should not refer to other documents in the medical record, such as "see the HMR", or "refer to the progress note" in order to complete any section of the 360 Comprehensive Exam. The only elements that may be pulled from a prior date of service would be as follows:

>> Surgical history >> Family history >> Lab results within the past 180 days are

preferable, however the most recent lab results within the last year are acceptable. ?? Diagnostic and/or preventive screenings,

such as mammography, colorectal, or bone density, (based on CMS quality measure and frequency range as indicated within 360 exam)

In preparation to complete the Comprehensive Exam, you will need the following information:

>> Patient chart/medical records >> Stars/HEDIS/Preventive - measures

due information (as noted by asterisks on the paper form) >> The 2018 - 360 Comprehensive Exam form

Page 1

360 Identifying Information ? to be completed in its entirety

>> Patient's first and last name >> Date of birth >> Date of service >> Patient ID >> Rendering health care professional

(provider that completes the 360) >> Patient's PCP name and NPI >> Location 360 was completed and

source of collected information Please note: Each page of the 360 Comprehensive Exam must include the patient's name, date of birth and date of service.

Reason for exam must be documented >> Acceptable reasons include phrases such as: ?? "Comprehensive Exam" ?? "360"

Past medical history (PMH) >> It is not necessary to document every condition the patient no longer has; please keep diagnoses pertinent to those that would best demonstrate the patient's health status, and/or those conditions that require medical follow-up or attention >> If there is no pertinent PMH please choose box "Reviewed and no past medical history"

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are

owned by Cigna Intellectual Property, Inc. ? 2018 Cigna

INT_18_63116 01192018

Page 1

Surgical history >> Please make note of the patient's surgical history, along with known date ?? If room is a factor, it is only necessary to document pertinent surgeries; examples would include CABG, PTCA, acquired absence of organ, pacemaker status, AAA repair, and/or ostomy status, etc. ?? Transplant status is a section designed to document if the patient has had a transplanted organ

Medications >> Please list all of the medications the patient is currently taking, including OTC's, with dosage and frequency >> If corresponding box is checked, you may attach a printed medication list or neatly printed list and this must be signed with provider's name, credentials and date (same as DOS)

Page 2

Fall risk screening >> Must be completed on all patients receiving the 360 exam >> Mark all that apply to the patient and add the total number of boxes checked at the bottom >> If the patient has none of the applicable risk factors please mark "0" as the total to assure we've noted it as addressed

Most common questions regarding fall risk screening

>> Diagnoses (3 or more existing) ? this would be 3 or more chronic, comorbid diagnoses (ex: DM, CHF & CKD)

>> Environmental hazard ? this is up to the health care professional's discretion

>> Polypharmacy ? defined as patients currently taking 4 or more medications

>> When applicable check box for: Unable to perform exam b/c of

>> Check box for: Fall risk (4 or more reported)

Depression screening >> Must be completed on all patients receiving the 360 exam >> If two or more "yes" boxes are checked please complete and attach either the PHQ 9 form, standard screening tool and/or clinical interview >> When applicable check box for: screening not performed because the patient is unable to communicate/answer

Urinary incontinence screening >> Must be completed on all patients receiving the 360 exam

Allergies >> Please document all known allergies and reaction or check box "No known drug allergies" >> Seasonal allergies do not apply here

Family history >> Complete this area as thoroughly as possible or document "Reviewed and no relevant history" if accurate >> If the family history is unknown or the section is left blank you must add statement of why (ex: adopted or dementia)

Habits and social history >> Please complete thoroughly including memory, vision, hearing, speech, illicit drug use, tobacco use, and alcohol use

Review of systems >> Check (EACH) negative box or document positive findings ? EACH system must be addressed (ROS: General, HEENT, Cardiac, Respiratory, GI, Musculoskeletal, Neurological, Skin, Psychiatric, Endocrine, Hematological, GU) >> Positive findings should include signs and symptoms >> If left blank, the 360 exam will have to be repeated during a new face-to-face date of service

Pain screening >> Must be completed on all patients receiving 360 exam >> Rate the overall pain presence in the patient's day-to-day life along with plan >> If the patient has no chronic pain, please mark 0 and document the plan as being N/A to assure we've noted it as addressed >> When applicable indicate reason if pain screen can't be completed (ex: dementia)

Foot exam >> Must be completed on all members that are diagnosed with diabetes, but may also be completed on patients with suspect conditions which would require a thorough foot exam >> At least 3 of the first 4 components must be addressed to reflect a completed diabetic foot exam >> In Box 5, please document any complications from the foot exam ?? The diagnoses marked in box 5 MUST correspond with current conditions section >> If there is a clinical reason why the foot exam is left blank, this reason must be documented (ex: amputation)

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Vitals >> All vitals must be documented; including a calculated BMI and patient gender

>> If there is a clinical reason why any of the vitals are left blank, the reason must be documented (ex: bedbound)

Comprehensive exam >> Must be completed by examining health care professional

>> Check (EACH) normal box or document abnormal findings ? EACH system must be addressed (PE: general, HEENT, neck, heart, lungs, breast,

Current Conditions ? Pages 3 through 6

>> Go through each diagnosis section and check current diagnoses and mark corresponding treatment and management plans ?? Treatment and management plans MUST be documented for EACH diagnosis selected

>> If the patient does not have a condition in a specific section, then document, "Reviewed and no active disease" if applicable

>> There are "Other diagnosis" spaces at the bottom of each section that allows for a diagnosis that is not listed to be documented

>> Be sure to identify additional selections for further specificity; some of the main diagnoses have additional options for specificity

Pay special attention: >> Cardiovascular ?? When documenting history of and/or MI diagnosis the date of MI must be noted ?? Specify the type of MI: ?? - Type 1 = NSTEMI and STEMI ?? - Type 2 =Demand ischemia etiology ?? - Type 4 = Percutaneous procedural etiology, i.e. coronary angioplasty and/or stenting ?? - Type 5 = Cardiac surgery etiology, i.e. CABG ?? Document specific type of heart failure as either left, right, diastolic, systolic, or combined systolic & diastolic ?? Specify the type of pulmonary hypertension based on etiology: ?? - Type 2 = left heart [mitral valve disease] ?? - Type 3 = lung disease [COPD] ?? - Type 4 = embolic [pulmonary embolus] ?? - Type 5 = multi-factorial [sarcoid & vasculitis] ?? When documenting hypertension indicate type and date of diagnosis, if known

abdomen, extremities, GU, musculoskeletal, neurological, skin, psychiatric, lymphatic, hematologic)

>> The breast, GU, and hematological exams may be addressed as deferred - Abnormal findings should include physical findings

>> Findings for medical and surgical history, ROS and diagnoses should be supported by the comprehensive exam if applicable

>> If left blank, the 360 exam will have to be repeated during a new face-to-face date of service

?? Consider linking primary diagnoses, i.e. hypertension to secondary co-morbid manifestations, i.e. chronic kidney disease

>> Nutritional/Metabolic/Endocrine ?? Document if the patient has malnutrition, obesity, and/or thyroid disorders ?? Consider documenting a co-morbid manifestation, i.e. hypertension or diabetes mellitus, when the patient has a BMI between 35.0 and 39.9.

>> Diabetes mellitus ?? Document the type of diabetic mellitus and also document all complications/manifestations ?? When chronic kidney disease (CKD) is linked to diabetes the stage of CKD must be documented in the renal/ urinary section of the 360 Comprehensive Exam ?? Complications foot exam (from page 2) should be documented here with appropriate diagnosis ?? Document insulin usage ?? Document Oral hypoglycemic/antidiabetic use ?? Stage any pressure ulcers ?? Specify laterality for skin disorders and eye complications

>> Respiratory ?? There are many pulmonary diagnoses in this section, remember to document the specificity and laterality of the applicable patient condition(s)

>> Musculoskeletal ?? In order to properly account for CMS STARS quality measure of rheumatoid arthritis, evidenced based practice suggests that patients be treated with a DMARD. The last DMARD prescription date needs to documented. In the event that there is a DMARD contraindication, the clinician should document why the DMARD has not been prescribed. If no DMARD has been prescribed provide a rationale for why the medication is not a part of the medical plan

Current Conditions ? Pages 3 through 6

?? The last bone mineral density scan date needs to be documented

?? If osteoporosis is documented check box "yes" or "no" for bisphosphonate prescribed and start date if "yes"

?? If fracture documented, indicate bone density test date

?? Include the laterality and specificity of the musculoskletal condition(s)

>> Skin/Subcutaneous ?? Specify the laterality, site, and stage of any skin ulcer(s)

>> Renal ?? Glomerular filtration rate (GFR) assessments should be completed on ALL patients regardless of current renal status ?? The GFRs should be reviewed for 3 months, and if > 60 a renal structural assessment (albumin creatinine ratio, micro-albumin, and/or renal sonogram) should be performed to determine the validity of the CKD ?? eGFR result and date drawn must be documented with CKD diagnosis ? Please wait for result and update; labs do not need to be attached, they simply need to be written in space provided ?? Document ESRD along with "yes" or "no" for dialysis

>> Gastrointestinal section ?? There are many gastrointestinal diagnoses in this section, remember to document the specificity of the applicable patient condition(s)

>> Eye section ?? There are many eye diagnoses in this section, remember to document the specificity and laterality of the applicable patient condition(s)

>> Active neoplasms/blood disorders and current treatment ?? Document all active malignancies as well as any metastases currently being treated

Page 7

Preventive medicine >> Each screening must be completed and/or recommended according to patient age and gender

>> Acceptable documentation includes date the screening was completed, declined, scheduled/ ordered/referred, not applicable to the patient, or when the patient was advised to have the exam ?? Scheduled/ordered/referred ? is defined as the completing provider's action on the 360 date of service (DOS) ?? Advised ? the patient agrees to the screening but may insist "not at this time"

?? Past history of neoplasms not currently being treated and under surveillance only should not be documented in this current conditions section. Resolved malignancies should be documented on page 1 of the form in the past medical history section

?? There are many active neoplasm/blood disorders in this section, remember to document the specificity and laterality of the applicable patient condition(s)

>> Neurological ?? Be specific when documenting sequelae of CVA. Late effect manifestations, such as monoplegia or dysphagia can develop 18 months after the acute CVA sentinel event

?? There are many neurological diagnoses in this section, remember to document the specificity and laterality of the applicable patient condition(s)

>> Psychiatric ?? There are many psychiatric diagnoses in this section, remember to document the specificity and laterality of the applicable patient condition(s) ?? When applicable the clinician needs to qualify: major depression - Severity (mild/moderate/severe [use PHQ-9]) - Single/recurrent episode(s) - Full or partial remission - If severe, denote if there are psychotic symptoms present ?? Recall the following substance use terms for tobacco, alcohol, and drugs: - Use = increases the risk of dependence/addiction - Abuse = poses harm or threats to a patient's physical and/or mental wellbeing ?? - Dependence = the requirement of a substance in order maintain a level of functioning and/or to prevent the manifestation of withdrawal symptoms ?? - Remission = no signs of substance use for at least 3 months (aside from craving), but less than 12 months

?? Declined ? means that the patient refuses ?? Not applicable - defined as the member's age

and gender do not fit the recommendation of the suggested screening examination >> The date the screening was completed should not be after the 360 DOS

>> Regarding colorectal cancer screening: at least one of the screening types must be addressed within the frequency range indicate

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>> Address advanced care planning ? conversation to be documented using check boxes

?? Given vaccine - pneumovax or prevnar

Long-term medication monitoring >> This section should be completed when patient's take anti-convulsant medications

>> Mark "reviewed" on all 360 exams (after completed)

>> Check all appropriate boxes ?? Anticonvulsant medication prescribed and date of serum drug concentration

Diagnosis specific sections >> These sections are expected to be completed based on the patient's documented diagnoses ?? Opioid Evaluation - Indicate whether the patient has > 15 days use of narcotic medications over the past 12 months for a non-terminal diagnosis, and if so whether any alternative options were offered ?? Patients with diabetes need to be asked about: ?? - statin medication ?? - last HgA1c date and result ?? - last micro-albumin date and result ?? - last retinal eye exam date and result ?? - name of retinal eye exam provider ?? Patients with CHF need to be asked about: ?? - Presence of ACE or ARB prescription ?? - Presence of beta blocker prescription ?? - Last left ventricular function (LVF) assessment date and result ?? ACE or ARB prescribed - check "yes" or "no" >> If labs are ordered on the date of service of the 360 exam, you should wait to include those lab results on the 360 to support documentation and diagnoses before submitting

Diagnoses >> Since current chronic conditions have already been documented, this space should be used for new diagnoses ? generally these are acute conditions specific to 360 DOS

>> Do not duplicate diagnoses already addressed in the current conditions

>> Provide written description of diagnoses. Do not provide ICD-10 codes

>> Treatment plan must be documented

Plan >> Any additional plans not already addressed may be documented here

Coordination of care >> List any health care professionals/specialists involved in the patient's care and any supplier of equipment >> Check the box for `none' is applicable

HMR reviewed and updated on today's visit >> If an HMR is completed on the same DOS, this box should be checked "yes" and the HMR should be attached

Case management and behavioral health referrals >> If you believe your patient has any case management or behavioral health needs, please check box "yes" and provide indication ?? Cigna HealthSpring will forward the referral to case management and behavioral health after processing

I discussed the following with my patient >> The following are related to healthcare quality surveys that are administered by CMS on an annual basis: Healthcare Effectiveness Data Information Set (HEDIS), Consumer Assessment Healthcare Providers & Systems (CAHPS), Health Outcomes Survey (HOS). Clinicians should consider discussing and documenting the following: ?? Tobacco cessation and education (current smokers) ?? Fall risk prevention (scores = 4 or higher in fall risk screening) ?? Urinary incontinence (with current diagnosis) ?? Physical exercise ?? Diet modification - High risk medications - 90 day medication refills

Other comments >> Any additional comments not already addressed may be documented here >> Patient email (optional)

Examiner name >> Must have printed name and signed with legible credentials >> Signature date must be included

If a 360 is completed by a nurse practitioner or physician assistant: Supervising physician name

>> Must be printed and signed with legible credentials >> Signature date must be included

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