An 18-month-old new patient presents for a well-child examination. During the encounter the physician uses 2 standardized screening instruments to screen for global developmental delays and autism spectrum disorder. Lead screening is also performed. The physician performs an age- and gender-appropriate history and examination and provides anticipatory counseling. Immunization counseling is provided by the physician, and the child is administered preservative-free quadrivalent influenza, diphtheria, tetanus, and acellular pertussis vaccine and hepatitis A vaccine. There are no abnormal findings, and the parents are instructed to make an appointment for the child’s next preventive service in 6 months and return sooner if necessary.
What are the appropriate procedure and diagnosis codes for this encounter? See answers elsewhere in this newsletter.