Access to quality primary care services is essential to the health and well-being of children and adolescents. Annual well-child visits are important for assessing growth and development, giving anticipatory guidance on nutrition and physical activity to maintain or improve functioning and helping combat obesity and childhood diabetes. Timely, consistent care from a Primary Care Physician (PCP) can provide screening for early detection of health issues, appropriate treatment, and preventative services, such as immunizations.

STAR KIDS can provide unique challenges in assessment; however, detailed assessments are vital for this population.

Some common issues noted in medical record reviews that prevent the record from closing the gap for the annual well-child visits (WCC) and Texas Health Steps (THSteps) include:

• Missing Body Mass Index (BMI) percentile (BMI alone does not count)
• Height (HT), Weight (WT), and BMI needed to determine BMI percentile
• HT and/or WT are often neglected due to a patient being a wheelchair user
• Missing documentation for Counseling for Nutrition with patients on enteral nutrition (tube feeding)
• Missing documentation for Counseling for Physical Activity with patients in wheelchairs and/or who lack mobility
• Missing documentation for Counseling for Physical Activity with parents of toddlers not yet in school or able to ride a bike, etc.

Recommendations

• Weigh empty wheelchair for baseline weight, then you can record an accurate assessment of the patient
• Use disposable 6-feet tape measures to record the stature of sitting or prone patient
• Record the discussion of the type and amount of enteral feeding to determine if it is sufficient for the healthy growth and development of the patient
• Document a referral to a nutritionist
• Document a “food diary” or documentation stating a well-balanced diet to include Protein, Veggies, Dairy, etc.
• A discussion and handouts are given on exercises that can be done from a wheelchair or lying-in bed for strengthening the upper body, legs, and core muscle groups
  •  A referral to Physical Therapists (PT) or Occupational Therapists (OT) does not count; however, the documentation of the following does count:  
    • Physical Activity: None
• A discussion on the physical activity the child/adolescent is involved in with the mention of time involved
  • Plays outside on a swing set, jumps on a trampoline, etc.
  • Physically active for more than an hour a day

Submitting complete ICD-10 coding with Current Procedural Terminology (CPT^®) Category II codes helps streamline your administrative processes and closes gaps in care. Get credit for the excellent care you provide your pediatric patients using proper codes. Minor adjustments in the documentation of vitals and patient education can make all the difference in a successful well-child visit.

Resources

THS Periodicity Schedule (HHSC)

Texas Health Steps Forms & Resources (HHSC)

Reference and review the Blue Cross and Blue Shield of Texas (BCBSTX) Preventive Care Guidelines (PCGs), Clinical Practice Guidelines (CPGs), and THSteps for Medical Providers, which includes all current vaccine schedules, ImmTrac2, and other important guidance for treating your patients.