99214/two chronic stable conditions

[BiscoDisco]

I was under the assumption having two chronic and stable conditions met criteria for 99214. If a patient has mdd and gad but requires no med changes or labs and everything is stable, my understanding was I could bill this as a 99214. Is this correct? I was recently told to bill this as a 213 by an attending.

Also when you document in your note, do you need to separate both problems and comment on each individually in the A/P?

Typically ill list the diagnoses, then write a 3-5 sentence blurb on my thoughts. Then I'll list the plan underneath. Does this seem sufficient?

---

Members don't see this ad.

 

[ObsequiousAplomb]

If you're a resident then code it as your attending is telling you.

Based on the definition of the 99214 this could be a 99214. I recommend explicitly saying why you're not making changes, e.g. symptoms in remission and absence of adverse effects, continuing current regimen to maintain stability.

 

[BiscoDisco]

If you're a resident then code it as your attending is telling you.

Based on the definition of the 99214 this could be a 99214. I recommend explicitly saying why you're not making changes, e.g. symptoms in remission and absence of adverse effects, continuing current regimen to maintain stability.

This is an external moonlighting gig - they weren't telling me what to do necessarily. Just what they would do.

 

[Stagg737]

It's a 99214 if you're prescribing meds. Not sure about the exact documentation requirements, but I list the diagnoses in the assessment and in the plan I'll say something like "Continue Lexapro 10mg daily for MDD and GAD". It should be clear why you're prescribing meds or how you're treating specific conditions you're addressing in one way or another.

 

[VA Hopeful Dr]

Prescribing medication isn't needed, all you need is "medication management". Stopping a medication counts, whether you prescribed it or not. Saying "condition stable no med changes needed" also counts.

 

[calvnandhobbs68]

I always separate out my diagnoses, even if I have meds treating the same thing, so I could justify in an audit, especially if it's something like MDD and GAD and they're only on an SSRI. In those cases I sometimes actually do "downcode" it to a 99213 + 90833 just cause it's easy and throw some 99213s in there.

So like:
1) MDD, recurrent, in partial remission- Chronic, stable
- Continue Prozac 40mg daily, no sig side effects, current dose effective for tx, continue to assess
- Some stuff about recommending continuing psychotherapy, lifestyle changes, addressing with therapy techniques during our appointments, etc

2) GAD- Chronic, stable
- Continue Prozac 40mg daily, no sig side effects, current dose effective for tx, continue to assess
- Another little blurb like the one above

 

[clozareal]

Prescribing medication isn't needed, all you need is "medication management". Stopping a medication counts, whether you prescribed it or not. Saying "condition stable no med changes needed" also counts.

I was also under the impression that considering medication changes also counts. Like if the patient doesn't want meds you can put something like "Recommended medication for depression. Patient declined. Will continue to discuss at follow-up appointments." and it counts toward "prescription medication management" for the risk/complications of patient management section of MDM.

 

[Stagg737]

Side question for the outpatient docs, do you specifically say if it's "chronic, stable" vs "acute exacerbation" or the status of every diagnosis? As in even something like GAD? I never did that because I made it pretty obvious in the HPI or other portions the current severity/status specific diagnoses, but have seen a bunch of people specifically writing that. Just curious if that's an actual requirement or if it's more to make things more obvious for billing departments as I never had to do this in residency but am seeing it more and more.

 

[calvnandhobbs68]

Side question for the outpatient docs, do you specifically say if it's "chronic, stable" vs "acute exacerbation" or the status of every diagnosis? As in even something like GAD? I never did that because I made it pretty obvious in the HPI or other portions the current severity/status specific diagnoses, but have seen a bunch of people specifically writing that. Just curious if that's an actual requirement or if it's more to make things more obvious for billing departments as I never had to do this in residency but am seeing it more and more.

I do it all the time, just to make it as explicit as possible for the ******* auditors when they try to claw back money from me. There are very specific definitions for "self limited" vs "acute" vs "chronic" and "complicated' vs "uncomplicated" diseases if you look at audit tools/coding guidelines....so if you don't specify it, it gives a lot more leeway to the auditors to decide if this illness is "acute" or "self limited" vs "chronic"

 

[docksan]

I was under the assumption having two chronic and stable conditions met criteria for 99214. If a patient has mdd and gad but requires no med changes or labs and everything is stable, my understanding was I could bill this as a 99214. Is this correct? I was recently told to bill this as a 213 by an attending.

Also when you document in your note, do you need to separate both problems and comment on each individually in the A/P?

Typically ill list the diagnoses, then write a 3-5 sentence blurb on my thoughts. Then I'll list the plan underneath. Does this seem sufficient?

You are correct, but still listen to the attending (if you're being supervised).

Two chronic conditions and medication discussion, by billing guidelines, meets criteria for moderate complexity.

You don't have to change meds, you don't have to prescribe, you only have to have made recommendations.

 

[BiscoDisco]

Prescribing medication isn't needed, all you need is "medication management". Stopping a medication counts, whether you prescribed it or not. Saying "condition stable no med changes needed" also counts.

What do you say when you have a pt on meds, their depression is waxing and waning and what they really need is a good therapist because theres a lot of personality going on? On one hand they are complaining of worsening depression but you arent changing meds at every single visit...is it sufficient to say recommend therapy?

 

[docksan]

What do you say when you have a pt on meds, their depression is waxing and waning and what they really need is a good therapist because theres a lot of personality going on? On one hand they are complaining of worsening depression but you arent changing meds at every single visit...is it sufficient to say recommend therapy?

I usually put "continue with these meds" in my plan with a blurb in my impression to satisfy the medication management requirement. Worsening depression meets criteria for exacerbation of symptoms.

 

[BiscoDisco]

I usually put "continue with these meds" in my plan with a blurb in my impression to satisfy the medication management requirement. Worsening depression meets criteria for exacerbation of symptoms.

Got that - but does it raise eyebrows if were saying worsening depression but we're not changing medications/increasing dose?

 

[calvnandhobbs68]

Got that - but does it raise eyebrows if were saying worsening depression but we're not changing medications/increasing dose?

No because psychotherapy is also a treatment. It'd be like if someone went to their family medicine doctor complaining of continued chronic knee pain, they're already on Meloxicam and the FM doc says what you need to do is go back to physical therapy, I don't think changing the meloxicam today is the right move.

 

[docksan]

Got that - but does it raise eyebrows if were saying worsening depression but we're not changing medications/increasing dose?

If you're giving clinical rationale why increasing the meds won't help and psychotherapy is useful, that counts as treatment discussion and technically you're prescribing therapy. Whether or not they go is not a factor in whether you can bill for it.

"Changing medication not likely to help with current depressive symptoms for (these reasons). Recommended psychotherapy and provided local resources today."

 

[J ROD]

Also, I like to point out the actual guidelines mentions problems, not diagnoses. Sort of a key point. Often times, I will have depression, anxiety, insomnia, or borderline outpatient. I tend to list the dx as well but just wanted to point that out. Easy to separate out the insomnia.

 

[VA Hopeful Dr]

Also, I like to point out the actual guidelines mentions problems, not diagnoses. Sort of a key point. Often times, I will have depression, anxiety, insomnia, or borderline outpatient. I tend to list the dx as well but just wanted to point that out. Easy to separate out the insomnia.

That's a good point to bring up. It's why I can't use flu, fever, and cough together to code higher than I can with flu alone.

 

[VA Hopeful Dr]

If you're giving clinical rationale why increasing the meds won't help and psychotherapy is useful, that counts as treatment discussion and technically you're prescribing therapy. Whether or not they go is not a factor in whether you can bill for it.

"Changing medication not likely to help with current depressive symptoms for (these reasons). Recommended psychotherapy and provided local resources today."

Referrals (which is what I would consider recommending therapy) are not as high a risk as medication management so it may not get you enough points to classify the level 4 on its own.

 

[VA Hopeful Dr]

What do you say when you have a pt on meds, their depression is waxing and waning and what they really need is a good therapist because theres a lot of personality going on? On one hand they are complaining of worsening depression but you arent changing meds at every single visit...is it sufficient to say recommend therapy?

So for depression (and remember I'm a family doctor so I do things differently than psychiatrists do), it's either stable or uncontrolled. If it's stable, I'm either refilling the medication at the current dose or potentially starting to wean off the medicine. If it's uncontrolled I'm likely either increasing the dose or adding some additional medication.

Stable depression alone will not get you a level 4. Uncontrolled depression will.

 

[nexus73]

The new rules make almost every visit 99214. This was supposed to help the cognitive specialties. But I've been seeing surgeons documenting things like this;

1. ENT:
   1. Follow up Tinnitus: ~ENT recs
   2. Obesity: recommend healthy diet and exercise
2. Ortho:
   1. Follow up knee pain: MRI
   2. nicotine abuse: advise cessation

To me these #2 problems are fraudulent to boost 99213 to 99214.
Meanwhile PCP's have like 9 problems per visit but hard to bill 99215 unless patient is near or actually being admitted to the hospital

 

[forchinet121]

The new rules make almost every visit 99214. This was supposed to help the cognitive specialties. But I've been seeing surgeons documenting things like this;

1. ENT:
   1. Follow up Tinnitus: ~ENT recs
   2. Obesity: recommend healthy diet and exercise
2. Ortho:
   1. Follow up knee pain: MRI
   2. nicotine abuse: advise cessation

To me these #2 problems are fraudulent to boost 99213 to 99214.
Meanwhile PCP's have like 9 problems per visit but hard to bill 99215 unless patient is near or actually being admitted to the hospital

How are those 2 problems fraudulent by the ENT or ortho?

 

[nexus73]

How are those 2 problems fraudulent by the ENT or ortho?

they’re only listing them to get to 2 problems to upcode the visit.

 

[calvnandhobbs68]

How are those 2 problems fraudulent by the ENT or ortho?

Um cause they’re probably actually fraudlent.

Aside from the fact that, if it happened it’d be totally odd to be counseled on your obesity when you’re going to ENT for tinnitus (even if losing weight was directly related to tinnitus somehow, it’d be addressing the tinnitus as a problem, not obesity), it very likely doesn’t even actually happen. They just see that the patient BMI is >30 and call it a problem they addressed.

 

[forchinet121]

Um cause they’re probably actually fraudlent.

Aside from the fact that, if it happened it’d be totally odd to be counseled on your obesity when you’re going to ENT for tinnitus (even if losing weight was directly related to tinnitus somehow, it’d be addressing the tinnitus as a problem, not obesity), it very likely doesn’t even actually happen. They just see that the patient BMI is >30 and call it a problem they addressed.

It’s not fraudulent, if you talk to the patient about obesity you can’t call that fraud just because they are surgeons..any physician can counsel on obesity or smoking cessation

 

[BiscoDisco]

So for depression (and remember I'm a family doctor so I do things differently than psychiatrists do), it's either stable or uncontrolled. If it's stable, I'm either refilling the medication at the current dose or potentially starting to wean off the medicine. If it's uncontrolled I'm likely either increasing the dose or adding some additional medication.

Stable depression alone will not get you a level 4. Uncontrolled depression will.

But stable depression and stable (GAD/BPD/social anxiety/etc) should get you that 214. That's my take away.

 

[VA Hopeful Dr]

But stable depression and stable (GAD/BPD/social anxiety/etc) should get you that 214. That's my take away.

As long as there is medication management, you are correct.

 

[calvnandhobbs68]

It’s not fraudulent, if you talk to the patient about obesity you can’t call that fraud just because they are surgeons..any physician can counsel on obesity or smoking cessation

Sure it’s technically not fraudulent in the way that doing 3 20 minute visits back to back an hour all being billed as 99214 + 90833 isn’t fraudulent…could you theoretically do it? Sure. Is it actually happening? Who knows, but highly doubtful. If you have the documentation to support it even if it didn’t happen are you going to get in trouble? Probably not.

 

[ObsequiousAplomb]

It’s not fraudulent, if you talk to the patient about obesity you can’t call that fraud just because they are surgeons..any physician can counsel on obesity or smoking cessation

Yeah, back when I was a medical student on rotations I do recall every single ENT and orthopod counseling their patients on weight loss and smoking cessation. The visit may have been for tinnitus, but the counseling for both came up. Often the secondary problem was discussed in the context of optimizing for potential procedures, but for things like tinnitus because obesity was an important medical problem for this patient. Obesity puts people at risk for all sorts of ENT problems like OSA. An ENT who doesn't counsel their patients to quit smoking would be very bizarre.

Orthopedists also should be counseling everyone who needs it on weight loss and smoking cessation. Both obesity and smoking are really bad for your bones and joints. I would be very surprised if it didn't come up for most patients.

 

[calvnandhobbs68]

Yeah, back when I was a medical student on rotations I do recall every single ENT and orthopod counseling their patients on weight loss and smoking cessation. The visit may have been for tinnitus, but the counseling for both came up. Often the secondary problem was discussed in the context of optimizing for potential procedures, but for things like tinnitus because obesity was an important medical problem for this patient. Obesity puts people at risk for all sorts of ENT problems like OSA. An ENT who doesn't counsel their patients to quit smoking would be very bizarre.

Orthopedists also should be counseling everyone who needs it on weight loss and smoking cessation. Both obesity and smoking are really bad for your bones and joints. I would be very surprised if it didn't come up for most patients.

Correct but there's a difference between actual counseling on weight loss (figuring out goals, referring to a nutritionist, talking about a realistic exercise plan, figuring out followup to track progress) and "I know you're here for your tinnitus but hey you know you should lose weight too because your BMI is 32".

Again, the line between actual treatment and upcoding gets blurry here.

 

[Stagg737]

Yeah, back when I was a medical student on rotations I do recall every single ENT and orthopod counseling their patients on weight loss and smoking cessation. The visit may have been for tinnitus, but the counseling for both came up. Often the secondary problem was discussed in the context of optimizing for potential procedures, but for things like tinnitus because obesity was an important medical problem for this patient. Obesity puts people at risk for all sorts of ENT problems like OSA. An ENT who doesn't counsel their patients to quit smoking would be very bizarre.

Orthopedists also should be counseling everyone who needs it on weight loss and smoking cessation. Both obesity and smoking are really bad for your bones and joints. I would be very surprised if it didn't come up for most patients.

I think the point was that it's fraudulent to just see a problem on a patient's list like obesity, tell them "you're obese and need to lose weight", and then count it toward a 214. You actually have to address the problem in some way, not just recognize it exists and inform the patient of that.

From C&H's link: "A problem is addressed or managed when it is evaluated or treated at the visit by the provider reporting the service. This includes consideration for further testing or treatment that may not be elected by reason of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or coordination of care documented does not qualify as being ‘addressed’ or managed by the provider reporting the service. Referring a patient to another provider without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the provider reporting the service."

That's a good point to bring up. It's why I can't use flu, fever, and cough together to code higher than I can with flu alone.

Actually, you can if you're addressing those symptoms separately. From the link C&H posted:

"A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, and/or other matter addressed at the visit, with or without a diagnosis being established at the time of the visit."

So you can document something like:

Lexapro 10mg daily for depression
Trazodone 50mg qhs prn for insomnia/sleep disturbance

And this should be enough to be considered addressing 2 problems, even if the insomnia is directly caused by the depression.

 

[ObsequiousAplomb]

Correct but there's a difference between actual counseling on weight loss (figuring out goals, referring to a nutritionist, talking about a realistic exercise plan, figuring out followup to track progress) and "I know you're here for your tinnitus but hey you know you should lose weight too because your BMI is 32".

Again, the line between actual treatment and upcoding gets blurry here.

I never saw the second example done. It was generally more often like the first.

 

[calvnandhobbs68]

I never saw the second example done. It was generally more often like the first.

So then they would be following up with ENT on their weight loss plan and ENT would be referring them to a nutritionist? If that actually happened that'd be admirable but I can't say I've seen that very often.

 

[ObsequiousAplomb]

So then they would be following up with ENT on their weight loss plan and ENT would be referring them to a nutritionist? If that actually happened that'd be admirable but I can't say I've seen that very often.

I can't say I've ever seen primary care do that. I don't think I've ever heard of a primary care doctor "managing" obesity with scheduled follow-ups. It's something that's addressed incidentally during care for other conditions. I'm sure dedicated weight loss clinics schedule follow-ups like that. Does that mean only a dedicated weight loss program can ever render care for obesity?

Not everyone needs a referral to a nutritionist every single time they meet with a doctor regarding their obesity. You don't need to be the only provider managing a condition to provide medical treatment for it. A specialist counseling someone is in itself a level of treatment. It isn't the moderate risk that the medication management is, but it is a service that is offered. How else do you propose providers bill for counseling patients on obesity, smoking, diet, exercise, etc, other than listing it in the assessment and plan?

Also, obesity would not be considered a stable condition. The definition of stable is supposed to be that it is at treatment goal, not that it has been unchanged. So while it's a chronic condition, unless the treatment goal has been met it's not yet stable.

Chronic knee pain would also only be stable if at treatment goal. Generally if Ortho is managing the chronic pain, it's probably not at treatment goal yet, unless there's a huge response to the treatment but for some reason a PCP or pain management aren't managing it.

Tinnitus would also only be stable once it's at goal. And tbh I'm not even sure what the goal generally is for tinnitus. Lack of progression? I don't treat tinnitus, obviously.

For us psychiatrists, despite it not being my personal goal, the recommended goal for MDD is complete resolution of symptoms, but I can't remember if that's APA or some other body that says that. I usually escalate treatment to patient satisfaction or the point of futility. So unless I'm at that, then it still wouldn't be stable. For people who I just can't get to complete remission, they might never be considered "stable" per the coding definition.

For schizophrenia I think it's reasonable to consider stable at 1/3 reduction of impact of symptoms on daily life, but I know plenty of psychiatrists who wouldn't consider it stable until there are no psychotic symptoms.

 

[sloh]

I think the point was that it's fraudulent to just see a problem on a patient's list like obesity, tell them "you're obese and need to lose weight", and then count it toward a 214. You actually have to address the problem in some way, not just recognize it exists and inform the patient of that.

From C&H's link: "A problem is addressed or managed when it is evaluated or treated at the visit by the provider reporting the service. This includes consideration for further testing or treatment that may not be elected by reason of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or coordination of care documented does not qualify as being ‘addressed’ or managed by the provider reporting the service. Referring a patient to another provider without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the provider reporting the service."

Bolded above leaves a lot of room for interpretation

 

[Stagg737]

Bolded above leaves a lot of room for interpretation

Sure, but you have to document it which leaves less gray area. If you don't document it, then it never happened...

 

[calvnandhobbs68]

I can't say I've ever seen primary care do that. I don't think I've ever heard of a primary care doctor "managing" obesity with scheduled follow-ups. It's something that's addressed incidentally during care for other conditions. I'm sure dedicated weight loss clinics schedule follow-ups like that. Does that mean only a dedicated weight loss program can ever render care for obesity?

https://www.aafp.org/dam/AAFP/documents/patient_care/fitness/obesity-diagnosis-mono.pdf

Table 4. The 5 A’s for Evaluation and Treatment of Obesity
Assess
Severity of obesity with calculated BMI, waist circumference, and comorbidities
Food intake and physical activity in context of health risks and appropriate dietary approach
Medications that affect weight or satiety
Readiness to change behavior and stage of change

Advise
Diagnosis of overweight, obese, or severe obesity
Caloric deficit needed for weight loss
Various types of diets that lead to weight loss and ease of adherence
Appropriateness, cost, and effectiveness of meal replacements, dietary supplements, over-the-counter weight aids, medications, surgery Importance of self-monitoring

Agree
If patient is not ready, discuss at another visit If patient is motivated and ready to change, develop treatment plan
If patient chooses diet, physical activity, and/or medication, set weight-loss goal at 10% from baseline
If patient is a potential candidate for surgery, review options

Assist
Provide a diet plan, physical activity guide, and behaviormodification guide
Provide Web resources based on patient interest and need
Identify method for self-monitoring (e.g., diary)
Review food and activity diary on follow-up (reassess if initial goal is not met)

Arrange
Follow-up appointments to meet patient needs
Referral to registered dietitian and/or behavioral specialist for individual counseling/monitoring or weight-management class
Referral to surgical program
Maintenance counseling to prevent relapse or weight regain

This is literally from the AAFP. I think most PCPs who are actually addressing obesity and weight loss with their patients would be a little perturbed that you're describing some surgeon randomly talking about someone needing to lose weight at an appointment that has nothing to do with their weight loss as the same level of management.

It's like the surgery clinics that do PHQ-9 screens on people who are depressed, say something to the patient about it and then count "depression" as a problem they addressed.

 

[VA Hopeful Dr]

I think the point was that it's fraudulent to just see a problem on a patient's list like obesity, tell them "you're obese and need to lose weight", and then count it toward a 214. You actually have to address the problem in some way, not just recognize it exists and inform the patient of that.

From C&H's link: "A problem is addressed or managed when it is evaluated or treated at the visit by the provider reporting the service. This includes consideration for further testing or treatment that may not be elected by reason of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or coordination of care documented does not qualify as being ‘addressed’ or managed by the provider reporting the service. Referring a patient to another provider without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the provider reporting the service."


Actually, you can if you're addressing those symptoms separately. From the link C&H posted:

"A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, and/or other matter addressed at the visit, with or without a diagnosis being established at the time of the visit."

So you can document something like:

Lexapro 10mg daily for depression
Trazodone 50mg qhs prn for insomnia/sleep disturbance

And this should be enough to be considered addressing 2 problems, even if the insomnia is directly caused by the depression.

We have been specifically told you can't just list symptoms of what you're treating and use that to upcode.

Your example is different since you're treating it separately from the depression.

A better example would be coding for depression and also coding for unhappiness. Yes it has a separate code but it's not a separate treatment from the depression.

 

[PsyDr]

IIRC: Discussion of side effects also counts.

 

[Stagg737]

We have been specifically told you can't just list symptoms of what you're treating and use that to upcode.

Your example is different since you're treating it separately from the depression.

A better example would be coding for depression and also coding for unhappiness. Yes it has a separate code but it's not a separate treatment from the depression.

Kind of? You can use symptoms treated to upcode if you're addressing them as a separate problem from a specific diagnosis. Keep in mind that "depression" is not a diagnosis, it's a symptom. Same thing with anxiety. When you write "continue lexapro 10mg daily for depression and anxiety" that is not the same as "continue lexapro 10mg daily for major depressive disorder and generalized anxiety disorder" even though we use those statements interchangeably.

I'd argue depression and "unhappiness" are the same thing, so that's a bit irrelevant. What you're saying is that you can't say use "lexapro for MDD" and then use "trazodone for sleep/sleep disturbance" as separate problems to upcode, which you most definitely can if you're addressing them as separate problems.

 

[VA Hopeful Dr]

Kind of? You can use symptoms treated to upcode if you're addressing them as a separate problem from a specific diagnosis. Keep in mind that "depression" is not a diagnosis, it's a symptom. Same thing with anxiety. When you write "continue lexapro 10mg daily for depression and anxiety" that is not the same as "continue lexapro 10mg daily for major depressive disorder and generalized anxiety disorder" even though we use those statements interchangeably.

I'd argue depression and "unhappiness" are the same thing, so that's a bit irrelevant. What you're saying is that you can't say use "lexapro for MDD" and then use "trazodone for sleep/sleep disturbance" as separate problems to upcode, which you most definitely can if you're addressing them as separate problems.

No, I'm saying you definitely CAN do exactly that (I do it frequently, 3 times today in fact).

What I'm saying is you can't use "Influenza A" and "fever" as two separate problems when it comes to coding. Otherwise I would never code a 99213 ever.

 

[hallowmann]

I can't say I've ever seen primary care do that. I don't think I've ever heard of a primary care doctor "managing" obesity with scheduled follow-ups. It's something that's addressed incidentally during care for other conditions. I'm sure dedicated weight loss clinics schedule follow-ups like that. Does that mean only a dedicated weight loss program can ever render care for obesity?

This is regularly done in a lot of primary care visits. Our routine in my training was to discuss diet/nutrition, refer if necessary, follow-up in 3-6 mos, if no improvement consider pharmacotherapy. This happened regularly in primary care clinics I was in med school as well in a different region. Its a huge goal of primary care and a measurable one at that, and now with GLP1s its also one that actually involves more effective pharmacotherapy.

Managing obesity is a huge part of preventative care, granted it often happen alongside the 10 other things the PCP is managing, so sometimes it takes a backseat to the 180/100 BP or decompensated CHF.

 

[clausewitz2]

This is regularly done in a lot of primary care visits. Our routine in my training was to discuss diet/nutrition, refer if necessary, follow-up in 3-6 mos, if no improvement consider pharmacotherapy. This happened regularly in primary care clinics I was in med school as well in a different region. Its a huge goal of primary care and a measurable one at that, and now with GLP1s its also one that actually involves more effective pharmacotherapy.

Managing obesity is a huge part of preventative care, granted it often happen alongside the 10 other things the PCP is managing, so sometimes it takes a backseat to the 180/100 BP or decompensated CHF.

I did my inpatient medicine rotations at a family medicine-run hospital and i read the description of obesity counseling and thought 'yeah that sounds like exactly what the FM residents did with their patients"

 

[ObsequiousAplomb]

This is regularly done in a lot of primary care visits. Our routine in my training was to discuss diet/nutrition, refer if necessary, follow-up in 3-6 mos, if no improvement consider pharmacotherapy. This happened regularly in primary care clinics I was in med school as well in a different region. Its a huge goal of primary care and a measurable one at that, and now with GLP1s its also one that actually involves more effective pharmacotherapy.

Managing obesity is a huge part of preventative care, granted it often happen alongside the 10 other things the PCP is managing, so sometimes it takes a backseat to the 180/100 BP or decompensated CHF.

I agree. It's important. It should be addressed at every visit or at least Q3 months.

I know that when I treat obesity as a psychiatrist I employ a very systematic and extensive approach just like was posted up-thread. I learned to do that back when I was a diabetes educator / weight loss educator for a research team in college. I polished it during the pre-clinical rotations in medical school. I was deeply disappointed to see it not happening on my multiple primary care rotations. I met exactly one family medicine doctor who did something like that, and his private practice shut down the same year I met him (it was an M2 ambulatory care rotation). I discuss all the weight loss options in terms of medications, various diets, the importance of the rate of weight loss, the roles for surgery, etc. Since I do a lot of evaluations pre-bariatric surgery I make sure to touch on all these points during the visit, though I'm certain the patient has already discussed it in detail with the surgeon, their PCP, and their various nutritionists. Since I'm taking such an extensive weight history and I am ruling out some medical and psychiatric comorbidities, I feel that it's important I bill the encounter to include this aspect of the care. While most surgeons are nowhere near this thorough, some are. Just as they bill for it so should we. PCPs bill for managing depression without any eyebrows when all they do is prescribe 90 days with 3 refills of sertraline 50 the second a patient mentions a psychiatric concern. They bill the same level of involvement as we do for a full visit.

On my 3rd and 4th year rotations in medical school, the PCPs generally mentioned weight loss as important but avoided prescribing or discussing weight loss meds due to the very onerous rules in that state regarding medications for weight loss. They generally referred all discussion and planning to a nutritionist or weight loss specialist, which aside from the initial assessment to refer someone out wouldn't count on follow-up billing.

On ENT rotations, the surgeon would obtain all the expected biometrics (weight, height, abdominal circumference, etc). They would discuss the weight loss and its role in their current presentation or possible future complications within that specialty. They would talk about how important weight loss was to managing lipids and hypertension and sugars. They would talk about OSA symptoms and risk factors and the importance of CPAP for helping reduce weight. They would ask what the patient has tried and suggest things to change. They would explore readiness to change. Similar things would happen on Ortho, depending on the attending in question.

I admit my experiences are not generally the norm in this regard. Many of the surgeons I rotated with graduated from my medical school, which was very aggressive on teaching primary care and lifestyle management of specialty conditions during all 4 years. Many of the PCPs did not (I went to a different IM and FM site than the main ones affiliated with my program). I imagine even within my year of my school most people had different experiences. I would be very annoyed if a 2 minute stitches removal surgery follow-up were billed as a 99214 if the second issue were summed up as "eat less" or "don't smoke" with nothing more going on.

I believe we were talking about different yet similar situations and it was the mass generalization that upset me and resulted in me posting so many long things counter to what else was said. Overall I agree that not discussing an issue thoroughly enough is inadequate. The question remains 'to what extent must something be addressed to be considered addressed?'

Do we need to run through every single potential adverse effect we discussed in the note? I doubt it. Do we need to say anything beyond our comment on the medication decision and that we referred for psychotherapy but patient declined in the plan? It wouldn't look like much more than what the surgeons documented in the posts at the top of the thread.

 

[nexus73]

I agree. It's important. It should be addressed at every visit or at least Q3 months.

I know that when I treat obesity as a psychiatrist I employ a very systematic and extensive approach just like was posted up-thread. I learned to do that back when I was a diabetes educator / weight loss educator for a research team in college. I polished it during the pre-clinical rotations in medical school. I was deeply disappointed to see it not happening on my multiple primary care rotations. I met exactly one family medicine doctor who did something like that, and his private practice shut down the same year I met him (it was an M2 ambulatory care rotation). I discuss all the weight loss options in terms of medications, various diets, the importance of the rate of weight loss, the roles for surgery, etc. Since I do a lot of evaluations pre-bariatric surgery I make sure to touch on all these points during the visit, though I'm certain the patient has already discussed it in detail with the surgeon, their PCP, and their various nutritionists. Since I'm taking such an extensive weight history and I am ruling out some medical and psychiatric comorbidities, I feel that it's important I bill the encounter to include this aspect of the care. While most surgeons are nowhere near this thorough, some are. Just as they bill for it so should we. PCPs bill for managing depression without any eyebrows when all they do is prescribe 90 days with 3 refills of sertraline 50 the second a patient mentions a psychiatric concern. They bill the same level of involvement as we do for a full visit.

On my 3rd and 4th year rotations in medical school, the PCPs generally mentioned weight loss as important but avoided prescribing or discussing weight loss meds due to the very onerous rules in that state regarding medications for weight loss. They generally referred all discussion and planning to a nutritionist or weight loss specialist, which aside from the initial assessment to refer someone out wouldn't count on follow-up billing.

On ENT rotations, the surgeon would obtain all the expected biometrics (weight, height, abdominal circumference, etc). They would discuss the weight loss and its role in their current presentation or possible future complications within that specialty. They would talk about how important weight loss was to managing lipids and hypertension and sugars. They would talk about OSA symptoms and risk factors and the importance of CPAP for helping reduce weight. They would ask what the patient has tried and suggest things to change. They would explore readiness to change. Similar things would happen on Ortho, depending on the attending in question.

I admit my experiences are not generally the norm in this regard. Many of the surgeons I rotated with graduated from my medical school, which was very aggressive on teaching primary care and lifestyle management of specialty conditions during all 4 years. Many of the PCPs did not (I went to a different IM and FM site than the main ones affiliated with my program). I imagine even within my year of my school most people had different experiences. I would be very annoyed if a 2 minute stitches removal surgery follow-up were billed as a 99214 if the second issue were summed up as "eat less" or "don't smoke" with nothing more going on.

I believe we were talking about different yet similar situations and it was the mass generalization that upset me and resulted in me posting so many long things counter to what else was said. Overall I agree that not discussing an issue thoroughly enough is inadequate. The question remains 'to what extent must something be addressed to be considered addressed?'

Do we need to run through every single potential adverse effect we discussed in the note? I doubt it. Do we need to say anything beyond our comment on the medication decision and that we referred for psychotherapy but patient declined in the plan? It wouldn't look like much more than what the surgeons documented in the posts at the top of the thread.

I agree it is possible ENT does this. Though improbable with a 40 patient clinic day.