Find information on school physical examinations, including clinical documentation requirements, medical coding guidelines, and healthcare resources. Learn about common diagnoses encountered during school physicals, recommended preventative services, and best practices for accurate and efficient documentation. Explore resources for pediatric healthcare providers, school nurses, and other medical professionals involved in conducting and documenting school physicals. This includes information on physical exam templates, ICD-10 codes related to school physical findings, and billing and coding compliance for school health services.
Also known as
Factors influencing health status
Encounters for general examinations and other factors influencing health.
Examination and observation
Encounters for administrative examinations.
Examination and observation
Encounter for school or educational purposes.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the encounter for administrative purposes only?
Yes
Z02.0 (Encounter for examination for administrative purposes)
No
Is there a specific complaint or concern?
When to use each related code
| Description |
|---|
| School Physical Exam |
| Well Child Exam |
| Sports Physical |
Using general codes like Z00.00 (Encounter for general exam) instead of specific school physical codes, impacting reimbursement and data accuracy. Relevant for medical coding, CDI, healthcare compliance.
Lack of proper documentation for services provided during the school physical can lead to claim denials and compliance issues. Important for medical coding, CDI, and healthcare compliance audits.
Upcoding or downcoding the Evaluation and Management (E/M) service level for a school physical, violating coding guidelines and posing compliance risks. Affects medical coding audits, CDI, and healthcare compliance.
School Physical Examination for (Patient Name), a (Age)-year-old (Gender) student, was conducted on (Date). The purpose of this examination is to assess the student's overall health and fitness for participation in school activities, including sports and academics. Review of systems was unremarkable. Past medical history includes (list any relevant past medical history, e.g., asthma, allergies, prior surgeries) with current medications including (list current medications and dosages). Family history is significant for (list relevant family history, e.g., hypertension, diabetes, heart disease). Immunization status is up-to-date per provided records. Physical examination revealed normal vital signs: blood pressure (BP) (record BP reading), heart rate (HR) (record HR), respiratory rate (RR) (record RR), temperature (Temp) (record Temp), and oxygen saturation (SpO2) (record SpO2). Height and weight were measured and plotted on a growth chart, demonstrating (e.g., normal growth, overweight, underweight) percentile. Head, eyes, ears, nose, and throat (HEENT) examination was normal. Cardiovascular examination revealed regular rate and rhythm without murmurs. Pulmonary examination revealed clear lung sounds bilaterally. Abdominal examination was soft and non-tender. Musculoskeletal examination revealed full range of motion and no abnormalities. Neurological examination was grossly intact. Developmental milestones are appropriate for age. Based on this examination, the patient is deemed (fit or not fit, with any specific restrictions) to participate in school activities. Recommendations include (e.g., follow-up for any identified concerns, healthy lifestyle choices, annual well-child visits). This documentation is intended for medical record purposes and may be used for healthcare, clinical documentation, medical billing, and coding. Diagnosis: School Physical (Z00.129 - Encounter for routine child health examination without abnormal findings).