Gold Standard Pediatric Feeding Evaluation Report Guide

Write pediatric feeding evaluations built around Texas Medicaid requirements, from the first line of history to the signed plan of care.

The Gold Standard Pediatric Feeding Evaluation Report Guide walks you through every section of a feeding evaluation and shows you what to document, what to consider clinically, and how each finding ties to medical necessity. Then it shows you three complete, annotated sample reports. It is written by Meagan Dungan, M.S., CCC-SLP, a VitalStim-certified pediatric feeding specialist, and its 17 sections match the Comprehensive Pediatric Feeding Evaluation Template so the two work side by side.

What's inside (74-page PDF)

• 3 worked, annotated sample reports (new): an infant bottle feeding after the NICU, a toddler with a G-tube and oropharyngeal dysphagia after a swallow study, and a school-age child with oral dysphagia and myofunctional concerns on a commercial plan. Each part is followed by notes on why it works for a reviewer.
• The medical necessity thread: how utilization reviewers read a feeding report, the path from history to testing, observation, trials, diagnosis, goals and plan, writing rules, and the words that invite a denial.
• The Pediatric Feeding Disorder framework: Goday 2019 criteria, all four domains, and acute versus chronic.
• 17 report sections, history to plan of care: what to document, clinical considerations, how to tie each to medical necessity, sample report language, red flags and referral triggers, and common pitfalls.
• Oral mechanism, TOTs, airway and clinical feeding exam explained, including trial design, aspiration signs, thickening safety and severity anchors.
• Three-part goal writing (new): every sample goal is written the way Medicaid reviewers look for it: the participation or medical reason (WHY), a measurable activity (HOW) and the deficit skilled therapy will improve (WHAT), for chewing, infant bottle feeding, liquid safety, food variety and caregiver training.
• Feeding Flock report writing: how to report PediEAT, ChOMPS, NeoEAT, EFS, Feeding Impact Scales and FaMM Feed using the current scoring method.
• Coding cheat sheet: ICD-10-CM (R63.31, R63.32, R13.1x, P92.x and more) with Excludes notes, CPT 92610 and 92526, modifiers, NMES billing, and sequencing examples.
• Referral guide: when to recommend an instrumental swallow study, VFSS versus FEES, what to put in the referral, and medical diagnosis considerations.
• Plan of care and prior authorization kit: Texas Medicaid plan of care elements, frequency criteria with justification language, a sample plan of care, prior authorization checklist, and progress summary template.
• 8 appeal letters and a peer-to-peer script for the most common feeding denials.
• Special situations (new): tube feeding and tube weaning, breastfeeding with the IBCLC, saliva management, pulse oximetry and cervical auscultation, telehealth evaluations, interpreters and family food culture, more caregiver-report tools, and documentation essentials like late entries, addenda and privacy.
• A pre-submission audit checklist to run on every report.

Pairs with

• Comprehensive Pediatric Feeding Evaluation Template ($15): collect the evidence with matching section numbers and 5 referral decision guides.
• Pediatric Feeding & Myofunctional Goal Bank ($35): 303 SMART goals in the same WHY + HOW + WHAT format, as a PDF and a filterable spreadsheet.
• Treatment Plan & SOAP Note Packet ($15): a standalone plan of care, SOAP note template with guidelines, and 95 feeding interventions defined.
• Save with the Evaluation + Report Bundle ($55) or the Complete Feeding Documentation Set ($85).

More from NTX: tethered oral tissues

For tethered oral tissues, NTX also offers specialized evaluations and protocols. Browse every resource on the Therapist Resources page.

Myofunctional (ages 2 and up)

• Pediatric Myofunctional Evaluation Template ($19): fillable tethered oral tissue evaluation for ages 2 and up: speech, feeding and airway.
• Myofunctional Therapy Protocol for Tethered Oral Tissues (3 Editions) ($97): pre-release to discharge, 14 exercises, in 3 kid-friendly editions.
• Myofunctional Evaluation + Protocol Bundle ($105): the myofunctional evaluation template and the 3-edition protocol.
• Complete Myofunctional Set ($135): myofunctional evaluation template, 3-edition protocol and goal bank.

Oral motor (birth to about 2)

• Pediatric Oral Motor Evaluation Template ($19): fillable tethered oral tissue evaluation for birth to about 2: feeding, airway and pre-speech.
• Tiny Tongues Infant Oral Motor Protocol ($97): therapist-provided oral motor protocol for infants and young toddlers, with a parent home routine.
• Oral Motor Evaluation + Protocol Bundle ($105): the oral motor evaluation template and the Tiny Tongues protocol.
• Complete Oral Motor Set ($135): oral motor evaluation template, Tiny Tongues protocol and goal bank.

Good to know

• Instant PDF download after checkout, plus an email with your download link.
• Single-clinician license. Please do not share or redistribute.
• Sample reports are fictional composites for teaching; never copy them into a real record.
• Texas Medicaid details are summarized from the TMPPM and plan guidelines current in October 2026. Payer rules change, so always check your current manual and MCO policies. This guide supports clinical judgment and does not replace it; it is not legal, coding or billing advice, and no resource can guarantee a payer's decision.