Wiki well child exam normal or abnormal

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Ctda2013

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We are getting a lot of questions also regarding what is a normal or abnormal for well child exam. Our providers have ordered a hearing screening and visual screening done with the well child exam. If the child fails either test, would that be an abnormal well child exam. Also, what dx code would you use on the screening tests. well child exam code or Z01.10, Z01.11 hearing normal or abnormal and Z0100, Z01.01 vision normal or abnormal.

I am getting all kinds of different thoughts.

Carla
Echo Community Health Care /FQHC
 
I believe failing the hearing and/or vision tests at the time of exam would be considered abnormal findings since they were discovered upon examination. They were not a patient complaint at the time of the encounter. Therefore use Z00.121. Use additional codes for hearing loss and/or abnormal visual acuity.

I can only offer my opinion on the second part of your question. If the primary purpose of the visit was for the general routine child health exam and not just for a vision and/or hearing screening, I would think that reporting Z00.121 or Z00.129 with the abnormal findings covers the situation.
 
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