Primary Care Coding Alert

Diet/weight problem offers E/M service coding opportunity


 Childhood obesity is still a major health issue, and FPs are a vital part of the medical community striving to prevent the disease's spread. Our experts reveal the CPT codes you should use for this work directive.

Address These Habits

 Before you code for the AMA's newly recommended dietary childhood assessments, get up to speed on the mandates- details. All children should -receive at least an annual assessment of their weight, dietary habits and physical activity levels,- according to the article -Expert Panel Gives Very Heavy Children a New Label ��" Obese- in the July 9, 2007, issue of American Medical News published by the AMA.  The assessment should address problematic issues, such as frequent restaurant dining, drinking large amounts of sweetened beverages, and excessive screen viewing time.

 The article calls for additional labs in problem patients. If the FP diagnoses the child as overweight, staff should measure the patient's blood pressure and pulse and order lipid studies. The physician should also test obese children's liver and kidney functions.

 Should you classify these assessments as preventive medicine counseling, preventive medicine services, or sick visits? Experts walk you through the coding do's and don't of these latest recommendations.

Don't Use 99401-99404 for Normal Assessment

 Question: Should you account for this weight-related work by using 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) in addition to the well checkup code?

 Answer: No. This code combination is incorrect for one simple reason. -CPT categorically does not allow you to report counseling and/or risk factor reduction intervention codes at the same encounter as a preventive medicine service,- says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare in Zanesville, Ohio. Physicians must provide 99401-99404 -at a separate encounter for the purpose of promoting health and preventing illness or injury,- says the AMA in CPT's counseling and/or risk factor reduction intervention introductory notes. The counseling and/or risk factor reduction intervention code family describes counseling in 15-minute increments.

 When an FP provides preventive medicine counseling at a preventive medicine service, you should report only the preventive medicine service (99381-99387 for new patients and 99391-99397 for established patients).

  Preventive medicine services include counseling/anticipatory guidance and risk factor reduction provided at the same encounter, according to CPT's preventive medicine services introductory notes.

 Not being able to charge 99401 with 99381-99387 or 99391-99397 probably won't hit your pocketbook. -Most plans consider 99401 a noncovered service,- says Nancy Reading RN, CPC, director of education for the American Academy of Professional Coders in Salt Lake City. -I would not bank on seeing extra revenue for this [CPT code].-

 Good news: -Some payers, such as Ohio Medicaid, may cover 99402-99404 when billed at a separate encounter from a preventive medicine service for anticipatory counseling guidance when the physician addresses issues such as diet and obesity prevention,- Tuck says. For instance, Ohio Medicaid covers the longer counseling sessions (99402-99404), but not the shorter (99401), he says.

Do Include Assessment in Well Check

  Question: Do these annual assessments entail any new work?

 Answer: No. -The new goals, in my opinion, are merely stating what should be done in every -well-child- checkup,- says Charles A. Scott, MD, FAAP, at Medford Pediatric and Adolescent Medicine in Medford, N.J.

 These new -guideline recommendations- should not create additional work for physicians who provide proper quality of care in their preventive medicine services,   Scott says.

 An annual physical already addresses the recommended aspects -- dietary habits, physical activity (and -why not- if the patient is inactive), growth and development including plotting height and weight, determining body mass index (BMI), along with anticipatory guidance after the complete physical examination.
 
Do Code for Diagnosed Weight Problem

 Question: Should you avoid labeling a patient during an assessment as overweight or obese?

 Answer: No. In fact, the AMA promulgates stricter guidelines for overweight and obese diagnoses use. Classify children as obese whose size puts them at or above the 95th percentile on the pediatric growth charts or who have a body mass index (BMI) higher than 30.

  Consider children who are between the 85th and 95th percentile overweight, say recommendations from the Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity, released June 6.

 In these cases, use the overweight/obesity diagnosis followed by the BMI diagnosis, as ICD-9 sequencing instructions state.

 For an obese child, use 278.00 (Obesity, unspecified) and V85.54 (Body mass index, pediatric, greater than or equal to 95th percentile for age). Code -overweight- as 278.02 and V85.53 (Body mass index, pediatric, 85th percentile to less than 95th percentile for age).

 Take-away tip: These diagnoses establish a distinct problem that could lead to more pay. If during the preventive medicine service, an FP diagnoses the patient as overweight or obese and performs the key components of a problem-oriented E/M service for this separate problem, he should report an office visit (99201-99215) in addition to the preventive medicine service.

 The AMA-recommended ordering and reviewing of lab work related to that diagnosis supports a separately billable E/M service. Append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to indicate that the office visit is significant and separately identifiable from the well-related service.

 Link the office visit to the supporting ICD-9 code, such as 278.00 and V85.54 for obesity or 278.02 and V85.53 for overweight. When treating the disease in the future, the physician can use follow-up and regular sick visit codes, Reading says. 

  Caveat: Not all payers will recognize obesity as a disease. Some payers may deny E/M services with only these diagnoses as -noncovered- services. You should check with payers regarding their individual policies on coverage of obesity/overweight as diseases before filing these claims.