The following documentation is from the health record of a male patient.
The following documentation is from the health record of a male patient. Well Child Check-Newborn This 18-day-old male patient is seen in clinic today for his second routine well check. following release from the newborn nursery with his first-time mom. He is spitting up much of his feedings and also is not latching on as well as he had been for the first six days. His weight is down 6 ounces to 6 pounds, 2 ounces and he is again below his birth weight. Remainder of the exam is normal. The mom is advised to reinstitute supplemental bottle feedings with pumped breast milk. She will see the lactation nurse this afternoon in the Woman’s Care Center for additional counseling on feeding problems. The patient will be seen again tomorrow in follow-up. If spitting up continues after appropriate latch response is achieved and it’s not related to excess air intake, will discuss switching to formula feeds. Diagnosis: Normal newborn with feeding problems Determine the correct diagnosis code assignment for this physician’s services. a. ZOO. 110, P92.5 b. ZOO. 111, P92.6 C. ZOO. 111 d. Zoo. 111, P92.5
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