Primary Care Coding Alert

Identifying optimal treatment is nearly impossible, which is a major reason why treating childhood obesity is difficult. However, recent studies performed by the American Academy of Pediatrics suggest that intervention is more helpful than previously thought.

• 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 (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 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: Per CPT^®, physicians and other qualified health care professionals who may report evaluation and management (E/M) services should use the appropriate E/M codes for MNT. These codes are typically reserved for certified dieticians and nutrition professionals, although many PCPs 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, the “assessment/ re-assessment and intervention” involves 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 have thorough documentation.

Preventive medicine: For patients undergoing obesity counseling related to, for example, diet and exercise and other risk factor reduction interventions, 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)

Per CPT^®, 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.

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.

Mind the E/M Guidelines

If you are reporting 99401-99404, be cautious about billing these counseling codes separately from a patient’s E/M service. 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 preventive medicine E/M service (99381-99397) and 99401, for example, on the same day. The preventive medicine E/M services include “counseling/anticipatory guidance/risk factor reduction interventions,” making 99401-99404 duplicative of the more comprehensive service.

Understand the Role of the Diagnosis

BMI by itself is not a diagnosis of obesity. In fact, related to Z68.-, ICD-10-CM guideline I.21.c.3 states, “BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity).” Diagnosis codes for obesity can be found under E66.- (Overweight and obesity).

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 PCP’s obesity diagnosis has a direct impact on which codes they can bill for counseling. For example, if the PCP counsels the patient about weight gain and nutrition without an obesity diagnosis but using only 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, the payer may decide MNT (e.g., code 97802) is not medically necessary and therefore not covered.

Without a diagnosis of obesity or some other problem, you would also not be able to use an E/M code from 99202-99215 for the counseling, since those CPT® codes are problem oriented. However, as noted, a diagnosis of a specific illness 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 an obesity diagnosis code to justify the service.

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.