In simple words: This code is used for a regular checkup for a healthy child when no problems are found.

This code is used for a routine child health examination where no abnormal findings are present.It covers well-child visits for children over 28 days old when the purpose of the encounter is primarily preventative care, such as developmental assessment, immunizations, or general health counseling.It is not to be used for encounters addressing specific complaints or illnesses.

Example 1: A 12-month-old child is brought in for a routine well-child check. The child receives their scheduled immunizations, developmental milestones are assessed, and the physician discusses feeding and sleep habits with the parents.No abnormalities are detected., A 5-year-old child is seen for a kindergarten physical examination.The physician performs a physical exam, reviews the child's immunization record, and discusses healthy lifestyle choices with the child and parents.No problems are found., A 16-year-old adolescent has a routine check-up that includes a discussion about risky behaviors, mental health screening, and a review of their vaccination status. No specific health concerns are identified.

Documentation should include the reason for the encounter (routine well-child check), the child's age, growth parameters (height, weight, head circumference if applicable), developmental milestones assessed, immunizations administered, anticipatory guidance provided, and the results of the physical exam.

** This code is a billable code used to indicate a reason for an encounter, and it should be used in conjunction with any procedure codes for services provided during the encounter.