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.