Pediatric Coding Alert

BMI key to coding the condition.

Obesity, the Centers for Disease Control and Prevention (CDC) tells us, affects about 12.7 million - about 17 percent - of children and adolescents between the ages of 2 and 19 (Source: https://www.cdc.gov/obesity/data/childhood.html). That's such a significant part of your practice's population that it's always a good idea to stay on top of the E66 (Overweight and obesity) codes.

But there are a number of other codes that you'll need to know when your provider works with a patient in this group. Read on, and keep this coding advice at your fingertips, too.

Begin with the Screen

Your pediatrician will probably begin by screening and counseling the patient, which you will record using one of the following preventive care codes:

• 99401 - Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
• 99402 - ... approximately 30 minutes
• 99403 - ... approximately 45 minutes
• 99404 - ... approximately 60 minutes.

Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, advises coders that these codes "are to be used when there is not a diagnosis code but when the child is inching closer to a higher body mass index [BMI]. The counseling involved," Holle elaborates, "is basically the same as that performed during a well-care visit [99381-99397] but is beyond what would be discussed during well care. This," Holle cautions, "is why these codes cannot be used with well care."  

Holle also reminds coders that these codes "are specific to time, which is different from using time as a key factor. So," she advises, "the documentation has to state the amount of time spent in this visit."

ICD-10 does not list a specific encounter code for obesity screening, but as obesity is very often a result of other conditions, you may be able to find an appropriate encounter code (such as Z13.21 [Encounter for screening for nutritional disorder]) to use in this situation.

Know BMI, Definitions ...

At the screening, says JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, Coding Manager at Children'sHealth Network in Minneapolis, Minnesota, your provider "will measure the patient's height and weight to arrive at the patient's BMI." However, unlike adults, because a child's body composition varies between ages and between genders, the CDC explains, "BMI levels among children and teens need to be expressed relative to other children of the same age and sex ... using an age- and sex-specific percentile."

This means that, for a child to be classified as overweight, per the CDC, the patient would have to be in the 85th-95th percentile of his or her age group, while a BMI in the 95th percentile or higher places him or her in the obese category.

ICD-10 does not define the terms "overweight" or "obese," but fortunately the terms correspond to the ICD-10 pediatric BMI codes of Z68.53 (Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age) and Z68.54 (... greater than or equal to 95th percentile for age). "Coders should then code this," Wolf advises, "along with the primary E66 diagnosis code as the diagnosis."

Holle agrees, adding that "many carriers vary in their reimbursement for these codes. So, if the provider is counseling on overweight/obesity," Holle observes, "payers will prefer high BMI codes for children as the diagnosis and not an obesity code."

Coding alert: Remember, the CDC's BMI calculations are different for adults, which they classify as being a person age 20 or above. So, if your provider still sees patients in their 20s, remember to use the adult BMI codes (Z68.1-Z86.4) for overweight (BMI of 25.0 to <30) and obesity (BMI of 30.0 or higher).

... Determine Dx

Once you've made this determination, finding the correct primary diagnosis code becomes easier. If your patient falls into the overweight category, you can go ahead and code E66.3 (Overweight), but if the patient is obese, you will code according to cause:

• E66.0- - Obesity due to excess calories
• E66.1- - Drug-induced obesity
• E66.8 - Other obesity
• E66.9 - Obesity, unspecified

You might also code the patient using a combination of cause and severity:

• E66.01 - Morbid (severe) obesity due to excess calories
• E66.2 - Morbid (severe) obesity with alveolar hypoventilation.

Wolf reminds coders that "If the patient has any chronic illnesses that the obesity affects, for example moderate persistent asthma [J45.40], these codesmay also be used."

Use An Ounce of Prevention

Wolf also reminds coders that aftercare is usually performed during an evaluation and management (E/M) visit using codes 99201-99215. "As the majority of time in these visits is spent in counseling," Wolf goes on, "they are usually billed based on time."

But, Wolf advises, "if the patient is being seen to discuss their diet with a nutritionist rather than by the clinician, then coders can use 97802-97804 [Medical nutrition therapy ...]."

Ultimately, as Holle explains, "for proper documentation, feedback to the provider is essential. In the long run," Holle concludes, "this makes billing for the services easier on the coders/billers and may quicken the process for reimbursement."