What CPT codes are used for the 2-month well-child visit?

Use preventive medicine code 99391 for established patients under age 1 year. First visit if new to practice uses 99381. If significant problem addressed beyond preventive care, add E/M (99212-99215) with modifier 25. Immunization administration uses 90460 (first component with counseling) plus 90461 for each additional component.

What immunizations are due at 2 months?

Document: vaccines due per ACIP schedule (DTaP, IPV, Hib, PCV13, Rotavirus, Hepatitis B dose 2), vaccines administered with lot numbers, site and route, VIS date provided, and consent obtained. Note combination vaccines if used. Document any vaccines deferred with reason. Include observation period for allergic reactions.

What developmental milestones should be documented at 2 months?

Document: social smile (responds to face/voice with smile), tracks past midline, lifts head when prone, coos and makes vowel sounds, and calms when comforted. Use standardized screening tool if available. Document parental concerns and address developmental red flags (no social smile, no tracking, floppy or very stiff).

What feeding assessment documentation is required?

Document: feeding method (breast, formula, combination), frequency and amount, feeding duration if breastfeeding, formula type if applicable, weight gain trajectory (healthy weight gain ~1 oz/day), and any feeding concerns (spitting, colic, poor intake). Include vitamin D supplementation status for breastfed infants.

What anticipatory guidance should be documented for the 2-month visit?

Document: safe sleep (back to sleep, room sharing, firm surface), feeding guidance (exclusive breast/formula through 6 months), tummy time importance, car seat safety (rear-facing), infant care (bathing, cord care if applicable, circumcision care), recognition of illness signs, and sibling adjustment. Demonstrates comprehensive preventive care education.

2-Month Well Child Visit Template - Infant Checkup

Primary Care — 2-Month Well Child Visit Template

Primary Care Pediatrics Updated: 11/7/2025

The 2-Month Well Child Visit Template is designed for pediatricians and family medicine providers conducting the standard 2-month well-child checkup. This template documents the comprehensive evaluation including growth assessment, developmental milestones, feeding status, 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, feeding history including breastfeeding or formula feeding, elimination patterns, physical examination including comprehensive assessment, immunization administration and scheduling, screening test results, assessment of infant health and development, anticipatory guidance for parents, and scheduling of next well-child visit. This template ensures thorough well-child care, tracks growth and development, supports immunization compliance, and provides essential parent education. Ideal for pediatric practices, family medicine practices providing pediatric care, and practices managing routine well-child visits.

Visit Information

Infant name, DOB, age: 2 months
Weight: [Weight] lbs, percentile: [X]%
Length: [Length] inches, percentile: [X]%
Head circumference: [HC] cm, percentile: [X]%
Growth: Appropriate / Concerns: [specify]

Developmental Milestones

Social: Smiles responsively, tracks objects
Motor: Lifts head when prone, holds head up briefly
Language: Coos, makes sounds
Concerns: None / [Specify]

Feeding History

Feeding method: Breastfeeding / Formula / Both
Feeding frequency: [Times per day]
Feeding amount: [Ounces per feed if formula]
Feeding concerns: None / [Specify]

Elimination

Urine output: [Wet diapers per day]
Stool output: [Stools per day]

Physical Examination

Vital signs: HR, RR, Temp
General: Appearance, activity, alertness
Head: Fontanelles, head shape
Eyes: Red reflex, tracking, alignment
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]
Hips: [Barlow/Ortolani]
Extremities: [Range of motion, symmetry]
Neurological: Tone, reflexes, Moro, grasp
Skin: [Normal / Rashes]

Immunizations

Administered today: [DTaP, IPV, Hib, PCV13, Rotavirus, HepB]
Reactions: None / [Specify if any]
Next immunizations: [Schedule]

Screening

Hearing: [If due]
Other: [As indicated]

Assessment

1) Well-child, 2 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
2) Immunizations: [Administered as above]
3) Anticipatory guidance: [Sleep, safety, development, feeding]
4) Follow-up: Return in [timeframe] for 4-month well-child visit

Parent Education

Development expectations, sleep safety, car seat safety, when to call, warning signs.