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1 sep, 2021

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Well-child assessment

Percentage of children (three-17 years old) who had an outpatient visit with their primary care provider or OB/GYN and who had evidence of counseling for nutrition and/or physical activity and had a BMI percentile documented in 2021.

 

Nutrition

Documentation must include the date and at least one of the following:

  • Discussion of current nutrition behaviors
  • Checklist indicating nutrition was addressed
  • Counseling or referral for nutrition education
  • Patient received nutrition education materials during visit
  • Anticipatory guidance for nutrition
  • Weight or obesity counseling

 

Documentation related to the child’s appetite or an observation such as being well-nourished alone is not indicative of nutrition counseling.

 

Actividad física

Documentation must include the date and at least one of the following:

  • Discussion of current physical activity behaviors
  • Checklist indicating physical activity was addressed
  • Counseling or referral for physical activity
  • Patient received physical activity educational materials during visit
  • Anticipatory guidance specific to the child’s physical activity
  • Weight or obesity counseling

 

BMI percentile

Documentation must include the date and at least one of the following:

  • Height, weight, and BMI percentile
  • BMI may be documented as a percentile or plotted on an age-growth chart

 

Best practices and yips for talking to patients

  • Create a structured field in your electronic health record for routine documentation of well-child assessments to achieve a higher performance on this measure.
  • Use a screening or assessment code at the time of the evaluation and management service, which should be billed in addition to the screening or assessment code.

 

Well-child counseling codes

Counseling
Code type
Code
Nutrition
CPT Code
97802-97804
HCPCS Codes
G0270, G0271, G0447, S9449, S9452, S9470
ICD-10 CM Codes
Z71.3
Actividad física
HCPCS Codes
G0447, S9451
ICD-10 CM Codes
Z02.5, Z71.82
BMI assessment
ICD-10 CM Codes
Z68.51-Z68.54
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