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A physician's best chance to get paid appropriately for treating obesity isto paint an accurate picture, using medical codes, of what he or she had to doand why.
When documenting a claim for care provided to an obese patient, a physicianwill use one of two codes for obesity in the currently mandated diagnosis codeset, says Mary Stanfill, coding practice manager for the American HealthInformation Management Association (AHIMA).
In the International Classification of Diseases, Ninth Revision,Clinical Modification code set, commonly known as ICD-9-CM, the diagnosiscode for obesity, unspecified, is 278.00 and the code for morbid obesity is278.01.
"For any physician, whether a primary care physician or a bariatricsurgeon, specifying the condition as morbid or severe is akey point," Stanfill says. "If they just say the patient is obeseor has a problem with obesity, but don't specify that it has progressed to amorbid obesity, then we have to use that unspecified code."
As for which evaluation and management (E&M) code to use from theCurrent Procedural Terminology (CPT) code set, which describes medicalprocedures performed by physicians and other providers, a primary carephysician might use any code from 99201, a new-patient visit, through 99215, amuch longer, more in-depth office visit, Stanfill says.
Each step up in those levels means that the doctor worked harder, she says.Doctors' work has been difficult to quantify because it has to do with whatkind of medical decision-making is required.
Often payers may be limited to only paying for things for certain reasons.So they typically look at both the ICD-9-CM and CPT codes to tell them whatthe physician did and why he or she had to do those procedures.
Don Bradley, MD, senior medical director for Blue Cross and Blue Shield ofNorth Carolina (BCBSNC), which recently announced it would begin payingphysicians for treating obesity, notes that in the past, a claim for an officevisit with a sole diagnosis of obesity would get denied. Starting April 1,BCBSNC will reimburse physicians for up to four visits a year with a soleICD-9 code of obesity.
"We think physicians have been doing some [weight] counseling fortime immemorial and coding for a comorbid condition," Bradley says."Where this will have a significant impact is if you have an obeseperson who has no specific comorbid condition, that will bereimbursed."
DEGREE OF DIFFICULTY
The comorbid conditions that frequently accompany morbid obesity willincrease the code level, Stanfill notes, and each of those conditions has itsown code as well. If a doctor has a patient who has hypertension and highcholesterol, and who is obese, it would behoove the doctor to code all three,she says.
"When it gets to the payer they might ask, `Why did you bill a level4?' for what typically would have been a level 3 for those who are notobese," she says. "So [doctors] need to remember to capture it[obesity]. Go ahead and bother to mark it, because it could help justify ahigher level of service."
As for metabolic syndrome, the code book does have a code, 277.7, for whatit terms "dysmetabolic syndrome X." A diagnosis typically involvesa patient who has two or more of four conditions: obesity, dyslipidemia,insulin resistance, and hypertension.
From the obesity perspective, if a physician diagnoses a patient as havingdysmetabolic syndrome X, he or she also should document obesity, hypertensionor the other manifestations leading to that diagnosis, Stanfill says.
On the other hand, even if the provider documents all four, it does notmean the patient necessarily has metabolic syndrome.
Along these lines, Stanfill notes that codes for impaired fasting glucose(IFG) and impaired glucose tolerance (IGT) were differentiated in 2003 in thenonspecific abnormal findings section of the code book. IFG (fasting plasmaglucose 100–125 mg/dl) and IGT (2-hour plasma glucose 140–199mg/dl) are indicative of pre-diabetes, as defined by the American DiabetesAssociation, and should be documented. However, neither is necessarilyconclusive for insulin resistance or metabolic syndrome.
Because obesity could be related to another medical problem, certaindiagnostic tests, such as thyroid or blood glucose tests, also should be codedin the visit, Stanfill says. Again, it would be important to capture obesityas part of the rationale for why a doctor is conducting the tests. Initialdiagnostic tests probably would be coded in the ICD-9-CM 278 obesity category,she says.
If it is known that a patient's obesity is due to some otherdiagnosed-disease process, the physician would code whatever that process is.It is a situation similar to when a patient is fatigued because ofhypothyroidism, in which case one would simply code the hypothyroidism. Butuntil that is diagnosed, one would code the fatigue, Stanfill says.
UPDATING CODES TO REFLECT PRACTICE, EVIDENCE
Stanfill notes that the code book currently does not define at what point apatient becomes morbidly obese, nor does it have a mechanism for capturingbody mass index (BMI), which doctors typically use to differentiatenormal-weight, overweight, obese, or morbidly obese patients.
However, the four organizations that cooperatively revise the codes arelooking at updating the codes for obesity, including a possible add-on codethat would allow doctors to capture BMI. Also being discussed is adding a codefor "overweight," with the understanding that it is part of theweight continuum and its inclusion could help improve statistics regarding thenation's weight problem.
"They are looking at codes to better reflect what we've learned inrecent years about obesity as more of a chronic condition that needs to becaptured," Stanfill says. "They are improving by leaps and bounds.I think we will see better codes in October 2005." 
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