Pediatric Coding Alert

Understand counseling criteria that justifies each code set.

Treating childhood obesity is difficult, as it is nearly impossible to identify an optimal treatment. However, recent studies performed by the American Academy of Pediatrics suggest that intervention is more helpful than previously thought.

Diagnosing obesity requires the clinician to calculate body mass index (BMI). However, BMI coding comes with some confounding criteria. Amid new focus on pediatric obesity intervention, we’ve created a comprehensive review to help you expand your BMI and counseling coding skills.

Recognize the Significance of BMI

Why it’s important: As “a high BMI can be an indicator of high body fatness,” a patient’s BMI “can be used to screen for weight categories that may lead to health problems,” though “it is not diagnostic of the body fatness or health of an individual,” according to the Centers for Disease Control and Prevention (CDC). This means a child’s BMI does not tell the full story of that child’s health, but it can be a significant indicator or predictor of possible problems.

Know the codes: Unlike adult BMIs, children’s BMIs are calculated as percentiles relative to their gender and age group. The codes look like this:

• Z68.51 (Body mass index [BMI] pediatric, less than 5th percentile for age)
• Z68.52 (… 5th percentile to less than 85th percentile for age)
• Z68.53 (… 85th percentile to less than 95th percentile for age)
• Z68.54 (… greater than or equal to 95th percentile for age)

How to calculate: According to the CDC, BMI “is a person’s weight in kilograms divided by the square of height in meters.” So, a 7-year-old boy who is 121.9 cm and weights 22.9 kg would have a BMI of 15.4. If figuring out percentiles based on height and weight sounds like more math than you care to consider, “an easy way to calculate this is to go to the BMI calculator available on the CDC website,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. Simply plug a patient’s height and weight information into the calculator, which you can find at www. cdc.gov/healthyweight/bmi/calculator.html, and let it do the rest. Note that patients under 2 years of age do not have values available from the CDC.

Coding caution 1: “Many electronic medical records [EMRs] will now provide the calculation as well. Though if only the patient’s height and weight are documented, I would not recommend assigning a BMI code since the BMI was not documented,” notes JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.

Consider the Counseling Codes

MNT: There are a couple of medical nutrition therapy (MNT) CPT^® codes you can use to document and track services related to the assessment and management of pediatric obesity on an individual basis, such as:

• 97802 (Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes)
• 97803 (Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes)

Note: Pediatricians are not automatically qualified to bill for medical nutrition therapy. These codes are reserved for certified dieticians, although many pediatricians do have the required qualifications or there might be a qualified healthcare professional (QHP) on staff that does — so your practice may be able to bill for them. Additionally, as the descriptor implies, the service must involve a thorough assessment of the patient’s nutritional status, development of an individualized treatment plan, as well as ongoing monitoring of evaluation and progress. So, if you’re going to report these codes, it’s important to submit thorough documentation.

Preventive medicine: For patients undergoing obesity counseling, you also have the option to choose among the following codes, depending on time as indicated in each descriptor:

• 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)

Outpatient E/M services: Codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient …) are also viable options for ongoing nutritional counseling, as long as certain criteria are met, which we’ll get into next.

Understand the Role of the Diagnosis

The patient must be found to have a BMI of 30 or more to justify reimbursement for weight loss counseling, according to many payers’ policies. Therefore, the pediatrician’s obesity diagnosis has a direct impact on which codes they can bill for counseling. For example, if the pediatrician counsels the patient about weight gain and nutrition without an obesity diagnosis, using an ICD-10 code such as Z68.53 (Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age) or Z68.54 (... greater than or equal to 95th percentile for age) to justify the service, you cannot report 97802.

Without a diagnosis, you would also not be able to use an office/outpatient evaluation and management (E/M) code from 99202-99215. However, a diagnosis is not required to report 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) …). This means that patients who fall just under the cutoff or who simply express concern over their future health can receive regular and adequate guidance without needing that diagnosis code to justify the service.

Mind the E/M Guidelines

If you are reporting 99401-99404, you might be tempted to bill these counseling codes separately from a patient’s E/M service. After all, you can do that with tobacco and alcohol cessation counseling codes. However, this is not the case with the obesity counseling codes. The CDC classifies obesity as a chronic condition, thus making it an illness.

These CPT^® codes have a “separate procedure” designation, which means that they are included in a more comprehensive service performed during the same encounter/same day. So, you would not bill a problem-focused E/M service and 99401, for example, on the same day.

In fact, CPT^® states that “risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.” That means you cannot use these codes (99401-99404) when the counseling is provided as part of the treatment for an illness.

Remember to Report SDoH

Socioeconomic status can play an important role in treatment outcomes, especially for children who don’t have much control over their environments. Social determinants of health (SDoH) continue to play a significant role in a patient’s medical history, so for that reason alone, be sure to report codes such as Z59.- (Problems related to housing and economic circumstances) and Z63.- (Other problems related to primary support group, including family circumstances). These codes will also contribute to medical decision making (MDM) if you’re leveling an encounter for MDM rather than time.