Resolved Visit w/ Z23 and Z71.89 as only dx codes

[PaulaP_44300]

Good morning,
I am needing help determining an appropriate primary diagnosis code for a patient that presents to establish care, discuss general healthcare needs including BMI and developing a plan for diet and exercise regimens and F/U, to discuss an upcoming child to be born coming up in the near future and immunizations needed and emotions and can someone help me determine an appropriate dx code for this visit. Most of the reason they presented was for "counseling" pretty much rather than a dx or tx of a condition per say. Would something with the BMI be okay to use?

Thank you for your help!

 

[Darcy]

What has the physician documented in Assessments/Diagnosis?

 

[PaulaP_44300]

What has the physician documented in Assessments/Diagnosis?

"Other Counseling" about the new baby coming ( self care) & Immunization needed (flu) and documented in the A&P.

 

[Darcy]

I feel the 2 codes you have chosen are good...you can't create a dx. If documentation is non-specific then the codes will reflect that also.