Coding case study: Hypertension and obesity

April 10, 2018

Consider this clinical scenario

Clinical scenario:

Chief Complaint: Mr. Jones is a 64-year-old male, who presents with hypertension and morbid obesity.  

History: Patient states he is less active now due to change in employment and has been eating more fast food lately due to his busy work schedule.

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Review of Systems

Constitutional: Negative for fever, chills, fatigue. 

Respiratory: Negative for cough and shortness of breath.  

Cardiovascular: Negative for chest pain, palpitations, and leg swelling.

Physical Exam

BP: 152/106  Pulse: 64

Temp: 99.6 °F (37.6 °C) BMI: 50.49 kg/m2

Height: 5’ 11.73” Weight: 369 lb 8 oz


Constitutional: He is oriented to person, place, and time.
He appears well-developed. No distress. Obese male seated in chair, pleasant, looks comfortable.

Neck: Normal range of motion. Neck supple. No thyromegaly present.

Cardiovascular: Normal rate, regular rhythm and normal heart sounds.

Pulmonary/Chest: Effort normal and breath sounds normal. 

Abdominal: Soft. Bowel sounds are normal. There is no tenderness. 

Musculoskeletal: Normal range of motion. He exhibits no tenderness. 

Assessment and Plan 

Hypertension, unstable, amlodipine (NORVASC) 5 MG tablet; Take 1 tablet (5 mg total) by mouth daily.  Dispense: 30 tablet; Refill: 11

Morbid obesity, BMI, 50.49 - Reinforced need to lose 10 to 20 percent of his current body weight through proper nutrition and increased physical activity

Documentation Coding Requirements

Hypertension

When documenting, include the following:

Typee.g. essential, secondary, etc.
Causal relationshipe.g. Renal, pulmonary, etc. 

 

Overweight and Obesity

When documenting, include the following:

CauseDue to excess calories, drug-induced
SeverityChoose one of the three options below
ComplicationWith alveolar hypoventilation

 

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ICD-10 Codes

I10 Essential (primary) hypertension 

I11.9 Hypertensive heart disease without heart failure 

I15.0 Renovascular hypertension

E66.01 Morbid (severe) obesity due to excess calories

E66.09 Other obesity due to excess calories

E66.1 Drug-induced obesity

E66.2 Morbid (severe) obesity with alveolar hypoventilation

E66.3 Overweight

E66.8 Other obesity

E66.9 Obesity, unspecified

Use additional code to identify body mass index (BMI), if known

Z68.1-Z68.45  Body mass index (BMI), adult