Pediatric Coding Alert

Question: Insurers keep denying claims with diagnoses that indicate high body-mass index (BMI). Which ICD9 Codes should I use?

Wisconsin Subscriber

Answer: You should probably report 278.00 (Obesity, unspecified). Use this ICD-9 code to indicate significant obesity that doesn't qualify as morbid obesity. Code 278.00 is also appropriate when the patient has a family history of the problem.
 
If, however, the child meets the definition of severe or morbid obesity, you should assign 278.01 (Morbid obesity). ICD-9 defines morbid obesity as "increased weight beyond limits of skeletal and physical requirements (125 percent or more over ideal body weight ), as a result of excess fat in subcutaneous connective tissues."
 
Exception: When the patient's increased weight is due to a medical condition, such as a thyroid problem, report the underlying condition instead of morbid obesity.
 
Problem: Insurers have different criteria for 278.00. Some companies make no payment on claims containing this diagnosis due to plan exclusions. 
 
Example: After a pediatrician diagnoses a 10-year-old boy with obesity, a nurse practitioner counsels the child on proper diet and exercise. The insurer doesn't cover obesity-related services. So you should code the appropriate-level office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient) with a diagnosis of unspecified obesity (278.00) and charge the patient for the service.