WELL CHILD CARE VISIT
Patient Name: _____________________________ DOB:__________________ Date: _______________
Height: __________ Weight: ___________ BMI % (<18 yo) _________ BMI Value (18 yo+) ___________
E&M/Office Visit Level: |
|
|
|
Office/Other Outpatient Visit |
New Pt |
Established Pt |
|
|
1-4 years old |
99382 |
99392 |
|
5-11 years old |
99383 |
99393 |
|
12-17 years old |
99384 |
99394 |
|
>18 years old |
99385 |
99395 |
|
Telehealth modifier: GT or 95 (audio and video) |
BMI Percentile Dx Codes (<18 years old) |
||
|
Z68.51 |
<5th percentile |
|
Z68.52 |
5th percentile to <85th percentile |
|
Z68.53 |
85th percentile to <95th percentile |
|
Z68.54 |
>95th percentile |
BMI Value Dx Codes 18+ year old: |
|||||||||||
|
Z68.1: 19.9 or less |
|
Z68.24: 24.0-24.9 |
|
Z68.29: 29.0-29.9 |
|
Z68.34: 34.0-34.9 |
|
Z68.39: 39.0-39.9 |
|
Z68.45: 70 or greater
|
|
Z68.20: 20.0-20.9 |
|
Z68.25: 25.0-25.9 |
|
Z68.30: 30.0-30.9 |
|
Z68.35: 35.0-35.9 |
|
Z68.41: 40.0-44.9 |
||
|
Z68.21: 21.0-21.9 |
|
Z68.26: 26.0-26.9 |
|
Z68.31: 31.0-31.9 |
|
Z68.36: 36.0-36.9 |
|
Z68.42: 45.0-49.9 |
||
|
Z68.22: 22.0-22.9 |
|
Z68.27: 27.0-27.9 |
|
Z68.32: 32.0-32.9 |
|
Z68.37: 37.0-37.9 |
|
Z68.43: 50.0-59.9 |
||
|
Z68.23: 23.0-23.9 |
|
Z68.28: 28.0-28.9 |
|
Z68.33: 33.0-33.9 |
|
Z68.38: 38.0-38.9 |
|
Z68.44: 60.0-69.9 |
Lead Screening (under 2 Yrs. of Age): ______________________________________________________________________________
Smoking:
Was the patient queried about smoking behavior? ⃝ Yes ⃝ No
Does the patient currently smoke? ⃝ Yes ⃝ No
Depression Screening:
- Little interest or pleasure in doing things? ⃝ Always ⃝ Sometimes ⃝ Never
- Feeling down, depressed, or hopeless? ⃝ Always ⃝ Sometimes ⃝ Never
Result: ⃝ Positive ⃝ Negative
Anticipatory Guidance:
Nutrition:
3 meals a day? ⃝ Yes ⃝ No
Healthy snack choices? ⃝ Yes ⃝ No
Avoiding junk food? ⃝ Yes ⃝ No
Avoiding whole milk? ⃝ Yes ⃝ No
Healthy eating? ⃝ Yes ⃝ No
Positive body image? ⃝ Yes ⃝ No
Iron source? ______________________________________________________
Physical Activity:
Exercise Type _____________________________________________________ Extracurricular Activity/Sports ________________________________________
Screen Time ______________________________________________________
Social Determinants:
Living Situation ____________________________________________________
Food Security _____________________________________________________
Interpersonal Violence ______________________________________________
Family Substance Abuse _____________________________________________
Dental Care ___________________________________________________________________________
Elimination ___________________________________________________________________________
Sleep ________________________________________________________________________________
Sexual Behavior ________________________________________________________________________
School _______________________________________________________________________________
Mental Health _________________________________________________________________________
Emotional Well-Being ___________________________________________________________________
Ability to get along with others? ⃝ Yes ⃝ No
Controls emotions? ⃝ Yes ⃝ No
Exhibits compassion and empathy? ⃝ Yes ⃝ No
Safety:
- Bicycle/helmet?
- Use of booster seat?
- Fire Safety?
- Injury Prevention?
Social History:
Smoke Free Home: _____________________________________________________________________
Father’s History: _______________________________________________________________________
Mother’s History: ______________________________________________________________________
ROS/Exam:
Const
Head/Face
Eyes
ENMT
CV
Resp
GI
GU
Integumentary
Musculo-Skeletal
Neuro
Notes from the Network-April 2024
Notes from the NetworkApril 2024Performance PaymentsThanks to the great care that our PACN practices provide to their patients, the PACN has distributed more than $4.5 million back to PACN practices for Quality care since inception. Additional payments for 2023...
April 2023 Bulletin
April 2023 BulletinHere is what your PACN Team and Member colleagues have been up to as we begin 2023:PACN-ACO education session was held on February 24th for Quality Reporting (MIPS) submission tips. Thanks to all our PACN-ACO participants for your engagement to...
This content is restricted to site members. If you are an existing user, please log in. New users may register below.