Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit; parent also concerned about deep grooves on premolars and possible cavity HISTORY OF PRESENT ILLNESS Luke presents for a well child visit. During the encounter, the provider noted deep grooves on the premolars. The parent reports his last dental visit was in the fall. The provider expressed concern for possible cavity and recommended dental follow-up soon. PHYSICAL EXAM Weight: 46 pounds. Oral: **Deep grooves noted on premolars, concerning for possible cavity.** ASSESSMENT 1. Well child visit 2. Deep grooves on premolars, concern for possible cavity PLAN 1. Well child visit: Routine preventive care provided today. 2. Deep grooves on premolars: Recommended the parent schedule a dental appointment in the near term for further evaluation and management of the premolar grooves and possible cavity. Last dental visit was in the fall. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings K02.9 - Dental caries, unspecified CPT CODES 99392 - Preventive visit, established patient, age 1-4 years ───────────────────────────────────────── CODES: CPT 99392 | ICD-10 Z00.121, K02.9