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Old 09-18-2009, 04:15 AM
vikas.maheshwari vikas.maheshwari is offline
Join Date: Apr 2007
Posts: 68
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Default Please suggest the code

i am thinking to provide these CPT for the following service can anyone suggest i am correct for the particular scenario or not


a 5 year old boy who is an established patient brought in for 5 year well-child visit.

DIET: Eats well-balanced meals, fruits, vegetables, and milk on a daily basis.
ELIMINATION: Voiding and stooling without concerns. No chronic diarrhea nor constipation.
SLEEP: Sleeps well at night without concerns.
DEVELOPMENT: Counts, imaginary play, knows colors, skips/hops, dresses self, recognizes ABC's, copies triangle.
IMMUNIZATION STATUS: No prior allergic reactions.
Family Hx
No Known Drug Allergy.
Vital Signs
HR: 117 b/min,
Resp: 22 r/min,
Temp: 97.9 F,
Height: 43.5 in, Weight: 51.4 lb, BMI: 19.1 kg/m2,
O2 Sat: 100 (%SpO2).
Vision Screening:
Unable to cooperate.

Audio Screening: 25 db HL
+ Right ear response: 500 Hz: Yes
1000 Hz: Yes
2000 Hz: Yes
4000 Hz: Yes
+ Left ear response: 500 Hz: Yes
1000 Hz: Yes
2000 Hz: Yes
4000 Hz: Yes.
Physical Exam
GROWTH PARAMETERS: Normal growth curves, see growth flowsheet. BMI normal
GENERAL: Well developed, well nourished, and in no acute distress.
SKIN: No rash, no lesions.
HEENT: Head: Normocephalic and atraumatic. Eyes: Positive bilateral red reflex. Extraocular muscles intact. PERRL. Funduscopic exam normal. Normal eyelids, conjunctavae and sclera. Ears: Bilateral canals and tympanic membranes clear. Normal appearance to pinna. Nose: Patent, normal external appearance to nose. Normal nasal mucosa, septum and turbinates. Oropharynx: Moist mucous membranes. Normal palate, no lesions. Normal dentition. Normal gums and lips.
NECK: Supple. No lymphadenopathy. Normal tone. Thyroid normal without enlargement, tenderness or masses.
RESPIRATORY: Clear to auscultation throughout all lung fields.
HEART: Normal S1 and S2. Regular rate and rhythm. No murmur.
ABDOMEN: Soft and nontender. No hepatosplenomegaly. No masses. Normal bowel sounds in all four quadrants.
BACK: No spinal deformities. No evidences of scoliosis.
EXTREMITIES: Warm and well perfused. No clubbing, cyanosis or edema. Normal gait.
GU: Tanner 1 normal. Testes bilaterally descended and no evidence of hernia.
NEUROLOGIC: Alert. Motor 5/5 upper and lower extremities symmetrically.
5 years old for well child check.
Safety and anticipatory guidance regarding: car/booster seat safety, poisening safety, nutrition, household safety, helmets, dental visits, strangers/touching, pool safety, firearm safety, no passive smoking & street safety; all discussed at length with caregiver who expresses understanding.
Follow up labs. Recheck vision and followup in clinic in one month or sooner p.r.n. any other problems or concerns.
Vikas Maheshwari
Operation Manager (Medical Billing & Coding)
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