Jonah Patel
Well-child examinations are routine health checks for children from infancy through adolescence. These examinations are designed to monitor a child's growth, development, and overall health. They can include assessments of vital signs, growth metrics like weight and height, head circumference, body mass index (BMI), and initial parental education on newborn care. During these visits, physicians may also review feeding patterns, check for signs of jaundice resolution, and ensure the child's growth is on track. However, what constitutes an abnormal finding during a well-child exam has been a subject of discussion. According to the ICD-10-CM guidelines, an abnormal finding refers to a newly identified condition or a change in the severity of a chronic condition during a routine physical examination. This could include issues like uncontrolled hypertension or acute exacerbation of chronic obstructive pulmonary disease. In the context of well-child exams, abnormal findings may encompass growth delays, abnormal BMI, developmental concerns, or vision and hearing issues.
| Characteristics | Values |
|---|---|
| General Examination | No complaint, suspected or reported diagnosis |
| Routine Child Health Examination | Abnormal findings |
| Vision Examination | Refractive errors (e.g. myopia or hyperopia) or structural eye conditions |
| Hearing Examination | No signs of structural or functional issues |
| Autism Screening | Formal developmental screening or autism-specific screening |
| Developmental Delays | Language, communication, gross and fine movements, social/emotional development, and cognitive/problem-solving skills |
| Growth | Height, weight, head circumference, and body mass index |
| Signs of Abuse | Bruises, burns, bite marks, multiple injuries at different healing stages |
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What You'll Learn
Identification of developmental delays and autism
Well-child examinations are an important opportunity to identify any potential developmental delays or signs of autism. These examinations are typically conducted during routine check-ups and involve developmental monitoring and screening. The American Academy of Pediatrics (AAP) recommends that all children undergo developmental and behavioural screening during regular well-child visits. This includes specific screening for autism spectrum disorder (ASD).
During a well-child exam, a doctor or nurse may ask parents questions about their child's development or interact directly with the child through talk and play to assess their milestones. Missing a milestone could indicate a potential problem, leading to further evaluation. Developmental screening uses formal questionnaires or checklists to assess areas such as language, movement, thinking, behaviour, and emotions. Tools like the Ages and Stages Questionnaire (ASQ) and the Screening Tool for Autism in Toddlers and Young Children (STAT) help identify developmental challenges and signs of autism.
If there are concerns about possible autism or developmental delays, a more comprehensive developmental assessment is conducted. This assessment considers the child's strengths and weaknesses and may be performed over multiple sessions and settings to account for variations in the child's behaviour and comfort level. Professionals conducting these assessments should have experience and expertise in evaluating young children with autism. It is also crucial to respect the family's culture and ensure effective communication, especially if English is not the primary language.
Identifying developmental delays and autism early is crucial, as it allows for early intervention and access to support services. Child Find programs and early intervention programs can provide services from birth to three years of age, and local public school systems offer support for children aged three and older. Additionally, a formal autism diagnosis is essential for accessing resources from government and insurance agencies. This diagnosis is typically based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which recognises persistent deficits in social communication and interaction and restricted, repetitive patterns of behaviour as key indicators of autism.
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Vision and hearing exams
During a vision exam, the doctor will check for refractive errors, such as myopia or hyperopia, as well as structural eye conditions. If any issues are found, the doctor may refer the child to a specialist for further evaluation and treatment. The doctor may also recommend a follow-up exam to monitor the child's vision and ensure that any issues are addressed. If a child fails an initial vision screening, it is often necessary to conduct a follow-up exam with a specialist. In the case that no underlying issues are found, despite the failed screening, the code Z01.020 is used.
The process for hearing exams is similar. The doctor will check for any signs of structural or functional issues. If the hearing exam is normal, the code Z01.10 is used. If there are any abnormalities, the code Z01.11 is used, and further evaluation and treatment may be necessary. If the hearing exam is conducted due to a previously failed hearing screening, the code Z01.110 is used.
It is important to note that the codes used for vision and hearing exams may vary depending on the specific findings and the child's age. These exams are crucial for identifying any potential issues with a child's vision or hearing, which can impact their development and education. Therefore, clear documentation of any abnormal findings is essential to ensure proper follow-up care and treatment.
In addition to vision and hearing exams, a comprehensive head-to-toe examination is recommended at each well-child visit. This includes reviewing interval growth, parent/caregiver-child interactions, and potential signs of abuse.
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Growth delays
The symptoms of growth delays can vary depending on the underlying cause. Some common signs to look out for include physical appearance, hormonal imbalances, and developmental delays. For instance, children with certain forms of dwarfism may have arms or legs that are out of proportion to their torso. Low thyroxine levels can lead to energy loss, constipation, dry skin, dry hair, and difficulty staying warm. Children may also show delays in reaching critical milestones such as rolling over, sitting up, crawling, and walking.
Delayed puberty is another sign of growth delay, with signs such as a lack of breast development in girls or the absence of testicular growth in boys. Cognitive and social challenges, speech and language difficulties, slow weight gain, memory and learning issues, and gastrointestinal problems can also indicate growth delays. It is important to note that these symptoms may vary between individuals and may not always be indicative of a growth delay.
Identifying and addressing growth delays early is crucial, as they can impact a child's physical and psychological development. Proper evaluation and intervention by medical professionals are essential to ensure the well-being of children experiencing growth delays.
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Abnormal BMI
Body Mass Index (BMI) is a calculated measure of body weight relative to height. It is an important indicator of healthy growth and development in children. However, it is not a perfect measure of body fat and should be considered alongside other factors such as a patient's medical history, health behaviours, physical exam findings, and laboratory findings.
BMI is used to assess a child's physical growth and is monitored over time to track a child's growth pattern. It is expressed as a percentile, which indicates how a child's BMI compares to others of the same gender and age. For example, a child with a BMI in the 60th percentile has a higher BMI than 60% of children of the same gender and age in the reference population.
An abnormal BMI in children can be classified as either underweight, healthy weight, overweight, obesity, or severe obesity. A healthcare provider will assess a child's height, weight, and BMI percentile at least annually to help monitor their growth relative to other children of the same age and gender. Accurate measurement of height and weight is important to obtain correct BMI calculations.
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Signs of abuse
Child abuse can be physical, sexual, emotional, or medical, as well as neglect. It is important to watch for red flags and warning signs, which may include:
- Changes in behaviour: Children may become more aggressive, angry, hostile, or hyperactive, or display regression to earlier behaviours such as thumbsucking, bedwetting, or fear of strangers. They may also appear scared, anxious, depressed, withdrawn, or lose self-confidence.
- Changes in school performance and attendance: Abused children may have difficulty concentrating, exhibit a sudden loss of acquired language or memory problems, or have excessive absences due to adults trying to hide their injuries.
- Fear of going home: They may express anxiety about leaving school or going places with the abuser or exhibit an unusual fear of a familiar person or place.
- Changes in eating and sleeping: Stress, fear, and anxiety can lead to changes in eating habits, resulting in weight gain or loss. They may also have frequent nightmares or difficulty falling asleep, appearing tired or fatigued.
- Lack of personal care or hygiene: Abused and neglected children may appear uncared for, consistently dirty, or lacking sufficient clothing for the weather.
- Risk-taking behaviours: They may engage in high-risk activities such as using drugs or alcohol or carrying a weapon.
- Inappropriate sexual behaviours: Children who have been sexually abused may exhibit overly sexualized behaviour or use explicit sexual language and may show symptoms of a genital infection.
- Unexplained injuries: Physically abused children may have burns, bruises, or broken bones with unconvincing explanations.
If you suspect child abuse, seek help immediately by contacting the appropriate authorities, such as the child's healthcare provider, a local child welfare agency, or the police department.
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Frequently asked questions
Abnormal findings on a well-child exam refer to any newly identified conditions or changes in the severity of existing chronic conditions. This includes issues like uncontrolled hypertension or acute exacerbation of chronic obstructive pulmonary disease.
The ICD-10 code for a routine child health examination with abnormal findings is Z00.121. This code is used when the examination identifies any issues, even minor ones, that require further evaluation or follow-up.
Abnormal findings during a well-child exam can include growth delays, abnormal BMI, developmental concerns, refractive errors in vision, or structural eye conditions. It is also important to look for potential signs of abuse, such as bruises on uncommonly injured areas, burns, human bite marks, or multiple injuries at different healing stages.
Billing for a well-child exam with abnormal findings depends on the specific circumstances. In some cases, providers can bill a separate office visit as long as they show that their work is in addition to the routine checkup. However, according to the Affordable Care Act, if the patient presents primarily for preventive care, you cannot charge a separate fee for an office visit.
