How would you code this

Herbie Lorona

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Pt mother brings pt in to office to be seen because she is concerned about the pts weight and eating habits. pt mother is concered he is to thin and thinks hes anemic. dr advises to watch pt eating habits and will keep a watch on the pts weight and reassure mother. what cpt and icd9 would you use?
 
well, I'd code the appropriate E/M level (what ever the documentation supports)
and I'd use a "feared complaint unfounded/worried well" dx code -V65.5
but, that's just my opinion....
 
I wouldn't code "underweight" unless the provider "states" underweight or another dx in the assessment or findings. To me, if the provider simply "reassured" the parent, watchful wait/observe that means what it means - no real problem - nothing to dx.
 
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