I am coding for a weight management facility where the patients are coming in for weight management/obesity counseling. Can we list/code their co-morbidities following the obesity and BMI code - even if the physician doesn't assess or treat the comorbidities? The comorbidities (such as HTN or Vit D deficiency) are mentioned only as "pt has history of xxxxx, xxxxx" in the HPI, but thats it. Then those comorbidities - and sometimes additional ones that weren't even mentioned in the HPI - are listed in the diagnosis list as "comment only". So my question is whether or not I can list all these comorbidities in addition to the obesity diagnosis. I've always been taught that if it wasn't part of the chief complaint and if it wasn't addressed, evaluated, and treated - then you don't code it or count it. But I'm finding that if I don't list the comorbidities, insurances are denying the claims with just the obesity and BMI diagnosis. Is it just a matter of the physician needing to do more documentation or can I bill the comorbities simply because they are listing them at the bottom of the office note?
PLEASE HELP !!
PLEASE HELP !!