Primary Care Coding Alert

Question: Does a patient’s status as morbidly obese automatically put a patient encounter at a level 5 when considering bariatric surgery?

New York Subscriber

Answer: Morbid obesity does not automatically translate into a level 5 evaluation and management (E/M) encounter. The encounter might end up being a level 5 because of comorbidities or other factors. It would all depend on the specific situation and the documentation of medical decision making or total time spent on the date of the encounter (in the case of Office/Outpatient E/M codes).

There could be counseling involved that revolves around morbid obesity and the possible surgery options, in which case total time spent could potentially bring the encounter to a level 5. But again, morbid obesity by itself does not equal a level 5.