Wiki Well Child Exam Question

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angel1101

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Hi
My name is Angela D.
I have a question that relates to well child exams.

If a 7 year old comes in for his routine well exam and the mom requests refills on his asthma medications but is not having any asthma related issues but they ran out of the refills; do we code the Well Exam as Well child with abnormal or is it Well child No Abnormal? If we refilled the meds does this qualify us to code an abnormal well visit? Thank you
 
There is no abnormal finding documented so no you cannot bill with abnormal finding. It is a reasonable and should be expected request that a patient ask for a med refill. You cannot charge extra for this and it is not an abnormality.
 
coding question re: Asthma and well exam

If at a well child exam the doctor notices the child is wheezing and does the breathing treatments and pft, discusses his current Asthma meds but has a history of Asthma so it is not a new diagnosis code, does the doctor diagnose the Well child with abnormal? or because he has a history of Asthma is it still considered Well with no abnormal? Thank you for your time, Angela
 
Z00 Encounter for general examination without complaint, suspected, or reported diagnosis.
This is the description for all Z00 diagnosis codes.
So if the child presents and is symptomatic or the provider suspected that there is an issue on presentation then it is not a well exam. If the child appears to be asymptomatic, with no complaints then it is a well child, if on exam the provider discovers an abnormality that was not obvious on presentation then it is a well visit with abnormal findings.
 
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