Diagnosis code-Can anyone help me

dsmith06351

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Can anyone help me with a diagnosis code? We have infants come in that are diagnosed with failure to thrive for inadequate weight gain, the doctor schedules a 3 month follow up for a weith check. The patient comes in after three months and the doctor writes the diagnosis of improved weight gain. What would the diagnosis be for the improved weight gain (or sometimes they write adequate weight gain)?

Thanks for any help

Denise Smith CPC-A
 
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V code

Denise ...
Is your doc stating the "failure to thrive" dx in the CURRENT documentation, or is it just in the patient's records?

I'm not positive ... but ... I'm thinking V67.9 (follow-up exam) and 783.41 (faillure to thrive) would describe this scenario.

F Tessa Bartels, CPC, CPC-E/M
 

LHand

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physician assessment v/s diagnosis

Adequate weight gain sounds like the doctor is writing his evaluation or assessment of that patients condition not giving them a new diagnosis.I agree with the previous writer on the failure to thrive diagnosis still being applicable.
 
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