Tina Posted Mon 13th of June, 2016 12:00:14 PM
A patient was seen for a preventive exam and the provider determines that the patient has an abnormal BMI. We code the E&M with the appropriate well with abnormal Dx listed as the primary, and the BMI listed as secondary. The provider also orders several labs as a result of the abnormal BMI. A specimen handling and venipuncture were also billed.
What Dx code should be listed as primary for the lab charges since coding guidelines states that the BMI codes should only be reported as secondary diagnoses. Can we bill the lab charges with the well with abnormal diagnosis as primary, or do we need to add another separate Dx code linked to the lab charges as primary with the BMI secondary? If so, would it be an obesity Dx or abnormal weight gain?
SuperCoder Answered Tue 14th of June, 2016 03:27:50 AM
Yes, BMI codes cannot be reported as primary diagnoses. You should report other dx such as overweight or obesity as primary dx and then you should report BMI as secondary dx if known. So please ask your physician to provide documentation if the patient was overweight or has obesity.