julieordway
Networker
What is considered significant enough to report an E&M visit with a well child check?
Here is an example I came across. Provider coded 99393. Would this support an E&M as well?
TIA
**WELL CHILD 7 year**
E is a 7-year-old male with ADHD and developmental delay presenting for his routine well child examination. He was previously referred for occupational and speech therapy and autism evaluation following his last visit one month ago.
Parental Concerns: Mother reports that E has been attending weekly occupational therapy sessions at Pediatric Therapy Services on Mondays, which are focused on developing skills to help him with his challenges. She has not yet received the evaluation packet from OHSU for his autism evaluation despite the referral being made a month ago. Mother notes that E has been snoring significantly at night, describing it as very loud snoring that requires repositioning him to stop. She reports that when he sleeps on one side, the snoring stops, and she does not observe any pauses in his breathing during sleep episodes. Mother expresses that she cannot see how much he is growing because she sees him daily, but her sister has commented that he is growing very fast. She is planning to continue with nutritional supplements for his ADHD management before considering medication options- taking Olly Calm gummies. Mother has not yet provided the school with documentation regarding his ADHD diagnosis for his 504 plan, as the school requested she wait until the autism evaluation is completed.
ROS
Additionally reports:
Nutrition/Elimination: E reports eating carrots and apples as fruits and vegetables, though he initially mentioned meatballs when asked about produce. He drinks water sometimes but needs encouragement to increase his water intake. He has a water bottle available for hydration. His stool consistency appears normal on the Bristol stool chart, and he reports no pain with bowel movements.
Dental: E brushes his teeth daily with maternal supervision. He has a dental appointment scheduled for tomorrow.
Sleep: E sleeps well overall but experiences significant snoring. Mother reports very loud snoring that was noticeable even when he was an infant. She manages this by repositioning him during sleep, and the snoring stops when he sleeps on one side. No breathing pauses or signs of sleep apnea are observed.
Development/Behavior: E has a diagnosis of ADHD and developmental delay. He is currently receiving weekly occupational therapy services to develop skills for his challenges. An autism evaluation referral has been made to OHSU but the family has not yet received the evaluation packet. He just completed first grade and will be entering second grade. He reports having a best friend in first grade and enjoys playing with magnets together. He demonstrates some difficulty with attention and focus during the examination.
Safety: Family plans to go swimming in the mornings for physical activity. Mother works and has established routines for after-school activities including lunch and swimming before work.
Health Risks: No concerns regarding secondhand smoke exposure, drug use, or sexual activity were discussed as age-appropriate.
Childcare/School: E just completed first grade and will be entering second grade. The school is aware of his ongoing evaluations and has requested documentation for his 504 plan once the autism evaluation is completed.
Physical Exam
PHYSICAL ASSESSMENT
GENERAL - Well-appearing, well-nourished male in no acute distress
HEAD – Normal head examination
EYES - Conjunctiva and lids: Normal conjunctiva and lids Pupils and irises: Normal pupils and irises Vision screening abnormal requiring ophthalmology referral
EARS, NOSE, MOUTH AND THROAT - External inspection of ears and nose: Normal external ears and nose Otoscopic examination: Normal tympanic membranes Normal ear canals Oropharynx: Normal oropharynx with good dental hygiene
NECK - Examination of neck: Normal neck examination
PULMONARY - Respiratory effort: Normal respiratory rate, rhythm, and work of breathing Auscultation of lungs: Clear lung sounds bilaterally
CARDIOVASCULAR - Auscultation of heart: Regular rate and rhythm, normal heart sounds
ABDOMEN - Examination of abdomen: Normal bowel sounds, no tenderness, no masses Examination of liver and spleen: Normal liver and spleen
LYMPHATIC - Palpation of lymph nodes in neck: No cervical or supraclavicular lymphadenopathy
MUSCULOSKELETAL - Normal muscle tone, development, and strength
SKIN - Skin and subcutaneous tissue: Normal skin and subcutaneous tissue
NEUROLOGIC - Sensation: Normal sensation Normal mental status
GENITOURINARY - Normal genitourinary examination, Tanner 1; chaperone offered and declined
Assessment / Plan
Hearing screening normal
1. Well 7-year-old male growing and developing as expected. Up to date on vaccines. Declined fluoride, has dental visits.
2. ADHD
3. Developmental delay
4. Abnormal vision screening
5. Snoring
PLAN/RECOMMENDATIONS
1. Next well visit at 8 years of age
2. Immunizations: No immunizations were administered today
3. Optometry referral declined as they have a family one to go to for abnormal vision screening
4. Continue weekly occupational therapy sessions at Pediatric Therapy Services
5. Contact OHSU to request autism evaluation packet as it was not received despite referral one month ago
6. Follow-up appointment in 6 weeks in mid-August before school starts to discuss ADHD medication options and review progress
7. Monitor snoring and return if worsening or if breathing pauses are observed during sleep
8. Provide school with ADHD documentation for 504 plan once autism evaluation is completed
Discussed growth parameters showing 62nd percentile for height and 64th percentile for weight indicating proportional growth. Emphasized importance of increased fruit and vegetable intake and adequate water consumption. Encouraged continued physical activity including planned swimming activities.
Counseling: Discussed the importance of nutrition including increased fruits and vegetables and water intake. Reviewed the benefits of continued occupational therapy for skill development. Discussed the need for optometry evaluation due to failed vision screening. Counseled on monitoring snoring and when to seek further evaluation. Reviewed the process for obtaining autism evaluation packet from OHSU and importance of completing this assessment.
Mother verbalized understanding of all recommendations and plans. She will contact OHSU regarding the missing evaluation packet and continue with scheduled occupational therapy sessions. Follow-up appointment scheduled for mid-August to reassess and discuss ADHD management options before school year begins.
Discussed results of SDOH and patient referred to resources.
Here is an example I came across. Provider coded 99393. Would this support an E&M as well?
TIA
**WELL CHILD 7 year**
E is a 7-year-old male with ADHD and developmental delay presenting for his routine well child examination. He was previously referred for occupational and speech therapy and autism evaluation following his last visit one month ago.
Parental Concerns: Mother reports that E has been attending weekly occupational therapy sessions at Pediatric Therapy Services on Mondays, which are focused on developing skills to help him with his challenges. She has not yet received the evaluation packet from OHSU for his autism evaluation despite the referral being made a month ago. Mother notes that E has been snoring significantly at night, describing it as very loud snoring that requires repositioning him to stop. She reports that when he sleeps on one side, the snoring stops, and she does not observe any pauses in his breathing during sleep episodes. Mother expresses that she cannot see how much he is growing because she sees him daily, but her sister has commented that he is growing very fast. She is planning to continue with nutritional supplements for his ADHD management before considering medication options- taking Olly Calm gummies. Mother has not yet provided the school with documentation regarding his ADHD diagnosis for his 504 plan, as the school requested she wait until the autism evaluation is completed.
ROS
Additionally reports:
Nutrition/Elimination: E reports eating carrots and apples as fruits and vegetables, though he initially mentioned meatballs when asked about produce. He drinks water sometimes but needs encouragement to increase his water intake. He has a water bottle available for hydration. His stool consistency appears normal on the Bristol stool chart, and he reports no pain with bowel movements.
Dental: E brushes his teeth daily with maternal supervision. He has a dental appointment scheduled for tomorrow.
Sleep: E sleeps well overall but experiences significant snoring. Mother reports very loud snoring that was noticeable even when he was an infant. She manages this by repositioning him during sleep, and the snoring stops when he sleeps on one side. No breathing pauses or signs of sleep apnea are observed.
Development/Behavior: E has a diagnosis of ADHD and developmental delay. He is currently receiving weekly occupational therapy services to develop skills for his challenges. An autism evaluation referral has been made to OHSU but the family has not yet received the evaluation packet. He just completed first grade and will be entering second grade. He reports having a best friend in first grade and enjoys playing with magnets together. He demonstrates some difficulty with attention and focus during the examination.
Safety: Family plans to go swimming in the mornings for physical activity. Mother works and has established routines for after-school activities including lunch and swimming before work.
Health Risks: No concerns regarding secondhand smoke exposure, drug use, or sexual activity were discussed as age-appropriate.
Childcare/School: E just completed first grade and will be entering second grade. The school is aware of his ongoing evaluations and has requested documentation for his 504 plan once the autism evaluation is completed.
Physical Exam
PHYSICAL ASSESSMENT
GENERAL - Well-appearing, well-nourished male in no acute distress
HEAD – Normal head examination
EYES - Conjunctiva and lids: Normal conjunctiva and lids Pupils and irises: Normal pupils and irises Vision screening abnormal requiring ophthalmology referral
EARS, NOSE, MOUTH AND THROAT - External inspection of ears and nose: Normal external ears and nose Otoscopic examination: Normal tympanic membranes Normal ear canals Oropharynx: Normal oropharynx with good dental hygiene
NECK - Examination of neck: Normal neck examination
PULMONARY - Respiratory effort: Normal respiratory rate, rhythm, and work of breathing Auscultation of lungs: Clear lung sounds bilaterally
CARDIOVASCULAR - Auscultation of heart: Regular rate and rhythm, normal heart sounds
ABDOMEN - Examination of abdomen: Normal bowel sounds, no tenderness, no masses Examination of liver and spleen: Normal liver and spleen
LYMPHATIC - Palpation of lymph nodes in neck: No cervical or supraclavicular lymphadenopathy
MUSCULOSKELETAL - Normal muscle tone, development, and strength
SKIN - Skin and subcutaneous tissue: Normal skin and subcutaneous tissue
NEUROLOGIC - Sensation: Normal sensation Normal mental status
GENITOURINARY - Normal genitourinary examination, Tanner 1; chaperone offered and declined
Assessment / Plan
Hearing screening normal
1. Well 7-year-old male growing and developing as expected. Up to date on vaccines. Declined fluoride, has dental visits.
2. ADHD
3. Developmental delay
4. Abnormal vision screening
5. Snoring
PLAN/RECOMMENDATIONS
1. Next well visit at 8 years of age
2. Immunizations: No immunizations were administered today
3. Optometry referral declined as they have a family one to go to for abnormal vision screening
4. Continue weekly occupational therapy sessions at Pediatric Therapy Services
5. Contact OHSU to request autism evaluation packet as it was not received despite referral one month ago
6. Follow-up appointment in 6 weeks in mid-August before school starts to discuss ADHD medication options and review progress
7. Monitor snoring and return if worsening or if breathing pauses are observed during sleep
8. Provide school with ADHD documentation for 504 plan once autism evaluation is completed
Discussed growth parameters showing 62nd percentile for height and 64th percentile for weight indicating proportional growth. Emphasized importance of increased fruit and vegetable intake and adequate water consumption. Encouraged continued physical activity including planned swimming activities.
Counseling: Discussed the importance of nutrition including increased fruits and vegetables and water intake. Reviewed the benefits of continued occupational therapy for skill development. Discussed the need for optometry evaluation due to failed vision screening. Counseled on monitoring snoring and when to seek further evaluation. Reviewed the process for obtaining autism evaluation packet from OHSU and importance of completing this assessment.
Mother verbalized understanding of all recommendations and plans. She will contact OHSU regarding the missing evaluation packet and continue with scheduled occupational therapy sessions. Follow-up appointment scheduled for mid-August to reassess and discuss ADHD management options before school year begins.
Discussed results of SDOH and patient referred to resources.