What CPT codes are used for well-child visits?

Preventive visits use age-based codes: 99392 (1-4 years), 99393 (5-11 years), 99394 (12-17 years), 99395 (18-39 years). For established patients, use 99392-99397 series. If significant problem addressed beyond preventive care, add E/M with modifier 25. Includes anticipatory guidance, developmental surveillance, and risk assessment.

What screening documentation is required for school-age visits?

Document: vision screening with results (refer if fails), hearing screening with results, BMI percentile with weight category (underweight, healthy, overweight, obese), depression screening for adolescents (PHQ-2/PHQ-9 results), and developmental/behavioral screening if concerns. Include laboratory screening if indicated (lipids at age 9-11, anemia if risk factors).

How should immunization status be documented?

Document: vaccines due per ACIP schedule, vaccines administered today with lot numbers, vaccines refused with reason (document informed refusal), and catch-up plan if behind. For adolescents, document HPV, Tdap, MCV4, and influenza status. Include patient/parent education on vaccine benefits and next vaccines due.

What developmental and academic assessment documentation is needed?

Document: grade level and academic performance, school concerns (learning, attention, behavior), social relationships, extracurricular activities, and developmental milestones appropriate for age. For adolescents, add HEADSS assessment (Home, Education, Activities, Drugs, Sexuality, Suicide/depression). Document any concerns and referrals made.

What anticipatory guidance should be documented for school-age children?

Document age-appropriate guidance: safety (helmet, seatbelt, water safety), nutrition (healthy eating, calcium/vitamin D), physical activity (60 min/day goal), screen time limits, sleep requirements (9-12 hours for school-age, 8-10 for adolescents), substance avoidance, and mental health. For adolescents, add confidential time discussion. Demonstrates comprehensive preventive care.

School-Age Checkup Template - Annual Pediatric Exam

Primary Care — School-Age Checkup Template

Primary Care Pediatrics Updated: 11/7/2025

The School-Age Checkup Template is designed for pediatricians and family medicine providers conducting annual well-child visits for school-age children (ages 5-18). This comprehensive template documents growth assessment, developmental milestones, school performance, behavioral assessment, physical examination, immunization status, screening tests, and anticipatory guidance. The template supports appropriate billing for well-child visits (CPT 99391-99395) and includes sections for growth parameters and BMI percentile, developmental milestones appropriate for age, school performance and academic concerns, behavioral and social development, physical examination including comprehensive assessment, immunization status and catch-up needs, screening tests including vision, hearing, and laboratory tests, assessment of child health and development, safety assessment including injury prevention, anticipatory guidance for parents and children, and scheduling of next well-child visit. This template ensures thorough well-child care for school-age children, tracks growth and development, supports school readiness and performance, and provides essential health and safety guidance. Ideal for pediatric practices, family medicine practices providing pediatric care, and practices managing routine well-child visits for school-age children.

Visit Information

Child name, DOB, age: [X] years
Weight: [Weight] lbs, percentile: [X]%
Height: [Height] inches, percentile: [X]%
BMI: [BMI], percentile: [X]%
Growth: Appropriate / Concerns: [specify]

Developmental Assessment

School performance: Good / Concerns: [specify]
Behavior: Appropriate / Concerns: [specify]
Social: [Peer relationships, activities]
Motor: [Age-appropriate skills]
Language: [Age-appropriate communication]

School History

Grade: [Grade level]
School performance: [Academic performance]
Behavior at school: [Behavior concerns if any]
Special services: [IEP, 504 plan, etc. if applicable]

Physical Examination

Vital signs: BP, HR, RR, Temp, BMI
General: Appearance, activity, alertness
HEENT: [Normal exam]
Cardiovascular: Heart rate, rhythm, murmurs, pulses
Respiratory: Rate, effort, breath sounds
Abdomen: Soft, non-distended, bowel sounds
Genitalia: [Tanner staging if age-appropriate]
Extremities: [Range of motion, symmetry]
Neurological: [Development, reflexes]
Skin: [Normal / Rashes]

Screening

Vision: [Screen results]
Hearing: [Screen results]
Laboratory: [CBC, lipids, etc. if indicated]
Other: [As indicated]

Immunizations

Status: Up to date / Needs catch-up
Administered today: [If any]
Next due: [Schedule]

Assessment

1) Well-child, [X] years old

Growth: Appropriate / Concerns: [specify]
Development: On track / Concerns: [specify]
School: Doing well / Concerns: [specify]

2) [Other diagnoses as applicable]

Plan

1) Continue routine care
2) Immunizations: [As needed]
3) Screening: [As indicated]
4) Anticipatory guidance: [Safety, nutrition, exercise, screen time, school]
5) Follow-up: Return in 1 year for annual well-child visit

Parent/Child Education

Age-appropriate guidance: Safety, nutrition, exercise, sleep, screen time, school, when to call, warning signs.