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How would you code this

  1. #1
    Default How would you code this
    Medical Coding Books
    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?
    Herbie W Lorona Jr., CPC, CPC-H

  2. #2
    Duluth, Minnesota
    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....
    Donna, CPC, CPC-H

  3. #3
    Greeley, Colorado
    I would avoid the "feared complaint" code if at all possible. Is the patient at all underweight? (783.22)...

  4. #4
    Dr. noted "Pt is in 15% percentile weight for age and 50% percentile height for weight"
    Herbie W Lorona Jr., CPC, CPC-H

  5. #5
    Duluth, Minnesota
    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.
    Donna, CPC, CPC-H

  6. #6
    Yeah he doesn't state anywhere that pt is underweight so I do agree with that. Only makes sense!
    Herbie W Lorona Jr., CPC, CPC-H

  7. #7
    NCF Gainesville
    You might ask the provider too, what makes the mom think the patient is anemic? Is the child fatigued? Just a thought.
    Jeni Smith, CPC, CPMA

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