What CPT codes are used for the 12-month well-child visit?

Use preventive medicine code 99392 for established patients ages 1-4 years. If significant problem is addressed beyond preventive care, add E/M code (99212-99215) with modifier 25. Immunization administration uses 90460 (first component through age 18 with counseling) plus 90461 for each additional component. Document vaccines with lot numbers.

What screening tests are recommended at 12 months?

Document: lead screening (universal or risk-based per AAP guidelines), hemoglobin/hematocrit for anemia screening, developmental screening (ASQ or similar tool), and autism screening initiation. Include results and follow-up plan for abnormal findings. Lead risk assessment should be documented even if not testing.

What immunizations are due at the 12-month visit?

Document: vaccines due per ACIP schedule (MMR, Varicella, Hepatitis A dose 1, PCV13 booster), vaccines administered with lot numbers, site and route, VIS provided, and consent obtained. Note any vaccines deferred with reason. Document catch-up vaccines if behind schedule and plan for completion.

What developmental milestones should be documented at 12 months?

Document: gross motor (pulls to stand, cruises, may take steps), fine motor (pincer grasp, bangs objects), language (1-3 words, follows simple commands, points), social/emotional (stranger anxiety, waves bye-bye, plays peek-a-boo), and cognitive (explores objects). Use standardized developmental screening tool and document results with interpretation.

What anticipatory guidance should be documented for the 12-month visit?

Document: nutrition (transition to whole milk at 12 months, self-feeding, cup use, weaning bottle), safety (car seat facing, childproofing, choking hazards, water safety), sleep (12-14 hours total, transitioning to one nap), development expectations, and dental care (first dental visit by age 1). Demonstrates comprehensive preventive guidance.

1-Year Well Child Visit Template - 12 Month Checkup

Primary Care — 1-Year Well Child Visit Template

Primary Care Pediatrics Updated: 11/7/2025

The 1-Year Well Child Visit Template is designed for pediatricians and family medicine providers conducting the standard 12-month well-child checkup. This comprehensive template documents growth assessment, developmental milestones including motor skills and language development, feeding transition to table foods, safety assessment, immunization administration, and anticipatory guidance. The template supports appropriate billing for well-child visits (CPT 99391-99392) and includes sections for growth parameters and percentiles, developmental milestones assessment including walking, talking, and fine motor skills, feeding history including transition to table foods and weaning, elimination patterns, physical examination including comprehensive assessment, immunization administration including MMR and varicella, screening test results including lead and hemoglobin, assessment of toddler health and development, safety assessment including home safety and injury prevention, anticipatory guidance for parents, and scheduling of next well-child visit. This template ensures thorough well-child care, tracks important developmental transitions, supports immunization compliance, and provides essential safety and nutrition guidance. Ideal for pediatric practices, family medicine practices providing pediatric care, and practices managing routine well-child visits.

Visit Information

Child name, DOB, age: 12 months
Weight: [Weight] lbs, percentile: [X]%
Length: [Length] inches, percentile: [X]%
Head circumference: [HC] cm, percentile: [X]%
Growth: Appropriate / Concerns: [specify]

Developmental Milestones

Motor: Pulls to stand, cruises, may walk, pincer grasp
Language: Says "mama/dada" specifically, follows simple commands, points
Social: Waves bye-bye, plays peek-a-boo, stranger anxiety
Concerns: None / [Specify]

Feeding History

Breastfeeding: Yes / No (if yes, frequency)
Formula: [Amount per day if applicable]
Table foods: Eating well / Picky eater / Concerns
Cup use: Using cup / Still bottle
Feeding concerns: None / [Specify]

Elimination

Diaper changes: [Per day]
Stool pattern: [Frequency, consistency]

Physical Examination

Vital signs: HR, RR, Temp
General: Appearance, activity, alertness
Head: Fontanelles (closing/closed), head shape
Eyes: Red reflex, tracking, alignment, visual behavior
Ears: External exam, response to sound
Cardiovascular: Heart rate, rhythm, murmurs, pulses
Respiratory: Rate, effort, breath sounds
Abdomen: Soft, non-distended, bowel sounds
Genitalia: [Normal exam]
Extremities: [Range of motion, symmetry, gait if walking]
Neurological: Tone, reflexes, development
Skin: [Normal / Rashes]

Immunizations

Administered today: [MMR, Varicella, HepA, PCV13 booster]
Reactions: None / [Specify if any]
Next immunizations: [Schedule]

Screening

Lead: [Level if checked]
Hemoglobin: [Level if checked]
Other: [As indicated]

Assessment

1) Well-child, 12 months old

Growth: Appropriate / Concerns: [specify]
Development: On track / Concerns: [specify]
Feeding: Going well / Concerns: [specify]

2) [Other diagnoses as applicable]

Plan

1) Continue current feeding plan / Recommendations: [specify]
2) Immunizations: [Administered as above]
3) Anticipatory guidance: [Development, safety, nutrition, sleep]
4) Follow-up: Return in [timeframe] for 15-month well-child visit

Parent Education

Development expectations, safety (home, car seat, choking prevention), nutrition, sleep, when to call, warning signs.