Primary Care Coding Alert

Question: An established patient who gained 20 pounds over the holidays reported to the FP for weight counseling. The FP performed a level-two E/M service. I am looking for the proper ICD-9 codes for this encounter. The patient is not obese, so I don't want to label him that in the medical record. Would you help?

Tennessee Subscriber

Answer: This scenario is the perfect time to use ICD-9 code 278.02 (Overweight). This diagnosis is ideal for patients who may be overweight, yet not clinically obese.

On your claim,

• report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M service.
• link 278.02 (Overweight) to 99212 to represent the patient's weight problem.
• link V65.3 (Dietary surveillance and counseling) to 99212 to represent the physician's actions during the encounter.

Don't forget BMI: On this claim, you should also include a V code to represent the patient's body mass index (BMI), if the patient's BMI is known. So if the FP decides the patient has a BMI of 27.0, you would link V85.23 (Body mass index 27.0-27.9, adult) to 99212.