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Ob-Gyn Coding Alert

Reader Questions:

Include BMI V Code on Weight-Related Encounters

Published on Thu Feb 15, 2007

Question: An established patient who gained 20 pounds over the holidays reported to the ob-gyn for weight counseling. The ob-gyn performed a level-two E/M service. I am looking for the proper ICD-9 codes for this encounter. The patient is not obese, so I don't want to label her with that in the medical record. What diagnosis should I use? Tennessee Subscriber Answer: This scenario is the perfect time to use 278.02 (Overweight). This diagnosis is ideal for patients who may be overweight yet not clinically obese. On your claim, report the following: - 99212 (Office or other outpatient visit for the evaluation and management of an established patient -) for the E/M service - 278.02 (Overweight) linked to 99212 to represent the patient's weight problem - a code that represents the patient's current body mass index (for instance, V85.25, Body mass index 29.0-29.9, adult) - V65.3 (Dietary surveillance and counseling) linked to 99212 to represent the physician's actions during the encounter.
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