Wiki Coding for an Obesity Clinic

[sfreytag]

Hi,

I recently became certified as a CPC and I am working for an obesity clinic. I have a question about the use of ICD-10 codes. Should we still be coding based on what all documentation states even if the providers aren't treating it? There are 4 specialties the patients see each in visit, Medical, Nutrition, Fitness, and Behavior. I review the documentation to verify the correct codes are being used and sometimes the providers add codes that are irrelevant to the services provided. The co-morbidities linked to obesity are certainly coded, but should I be coding for claustrophobia, migraines, and knee pain if the patient is complaining, or admitting to these issues in the HPI and ROS? My training in CPC taught me to code for everything documented, but this is a different type of specialty so I was wondering if anyone out there could provide some information on this topic.

Thanks you so much!
Staci

 

[coding4fun]

obesity

Hi Staci,
My clinic just started an obesity clinic. I code based upon what the documentation states as well as taking the insurance carrier specifics in consideration. Allow me to give you an example of a typical visit of one of our patients.

Mrs Smith comes to the wt loss clinic today for a wt loss followup. While discussing her weight loss, food log, BMI and reviewing wt loss handouts, Mrs Smith asks that her knee be looked at because it hurts all the time. The physician examines the knee and gives a medication which will aid in the pain of her knee. The visit has no other issues reported. I would code the obesity counseling (ICD10 codes of BMI, wt loss counseling plus the other codes which are effected by Mrs Smith weight to include DM2, HTN, HLP, etc) and an OV to cover the knee examination.

Typically if the visit is simple my docs do not code an OV but if non-related items are examined, then we code an OV. Hope this info helps