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    Coding case study: Hypertension and obesity

    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.This article appears in the 4/10/18 issue of Medical Economics.

    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:

    Type

    e.g. essential, secondary, etc.

    Causal relationship

    e.g. Renal, pulmonary, etc. 

     

    Overweight and Obesity

    When documenting, include the following:

    Cause

    Due to excess calories, drug-induced

    Severity

    Choose one of the three options below

    ❚  Overweight

    ❚  Obesity

    ❚  Morbid (severe) obesity

    Complication

    With 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

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