Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 33

Pediatric Obesity

Julie LaMothe

I. INTRODUCTION

A. Obesity (BMI above the 95th percentile) is increasing among children and adolescents. Pediatric obesity has tripled since 1980. A majority of obese children remain obese as adults. The risk of pediatric obesity is related to childhood diet and sedentary time. Obesity is associated with higher blood pressure, elevated blood lipids, insulin resistance, impaired glucose tolerance, and increased risk of several chronic diseases of adulthood, including diabetes, hypertension, dyslipidemia, sleep apnea, cardiovascular disease (CVD), fatty liver, metabolic syndrome, hepatic stenosis, orthopedic complications, pseudotumor cerebri, and some cancers. In addition, obesity in childhood can have psychosocial implications including low self-esteem, impaired quality of life, and depression.

II. CODING FOR OBESITY

A. Many insurance carriers will deny claims submitted with obesity codes. The following is a guide to coding for obesity-related healthcare services: “Obesity and Related Comorbidites Coding Fact Sheet for Primary Care Pediatricians,” from the NICQUE Academy of Pediatrics.

B. Additional resources include:

1. Pediatric Coding Companion, from the NICHQ Academy of Pediatrics.

2. Coding and reimbursement for children with abnormal weight gain in primary care, from the NICHQ Academy of Pediatrics.

3. Denials (Strategies and a Template letter for pediatric practices), from the AAP Member Center.

4. AAP Hassle Factor Form, from the AAP Member Center.

C. Codes for procedures.

1. Calorimetry, 94690.

2. Glucose monitoring, 95250.

3. Venipuncture, 36415.

D. Healthcare Common Procedure Coding System (HCPCS) education and counseling codes.

1. S9445, patient education individual.

2. S9446, patient education group.

3. S9449, weight management class.

4. S9451, exercise class.

5. S9452, nutrition class.

6. S9454, stress management class.

7. S9470, nutrition counseling.

E. Common diagnosis codes, ICD-9-CM codes.

1. Circulatory system.

a. 401.9, hypertension.

b. 429.3, cardiomegaly.

2. Congenital anomalies.

a. 758.0, Down syndrome.

b. 759.81, Prader-Willi syndrome.

c. 759.89, other specified anomalies.

3. Digestive system.

a. 530.81, esophageal reflux.

b. 564.00, constipation.

c. 783.3, feeding difficulties and mismanagement.

d. 571.8, other chronic nonalcoholic liver disease.

e. 789.1, hepatomegaly.

4. Endocrine, nutritional, metabolic.

a. 244.8, other specified acquired hypothyroidism.

b. 244.9, unspecified hypothyroidism.

c. 250, diabetes mellitus, type 2 or unspecified type, uncontrolled.

d. 253.8, other disorders of the pituitary.

e. 255.8, other disorders of the adrenal glands.

f. 256.4, polycystic ovaries.

g. 259.1, precocious sexual development and puberty.

h. 259.9, unspecified endocrine disorder.

i. 272, pure hypercholesterolemia.

j. 272.1, pure hyperglyceridemia.

k. 272.2, mixed hyperlipidemia.

l. 272.4, other and unspecified hyperlipidemia.

m. 272.9, unspecified disorder of lipoid metabolism.

n. 277.7, dysmetabolic syndrome X/metabolic syndrome.

o. 278, obesity, unspecified.

p. 278.01, morbid obesity.

q. 278.02, overweight.

r. 278.1, localized adiposity.

s. 783.1, abnormal weight gain.

t. 783.4, lack of normal physiological development.

u. 783.43, short stature.

v. 783.5, polydipsia.

w. 783.6, polyphagia.

5. Genitourinary system.

a. 611.1, hypertrophy of the breast.

6. Mental disorders.

a. 300, anxiety state, unspecified.

b. 300.02, generalized anxiety disorder.

c. 307.5, eating disorder, unspecified.

d. 307.51, bulimia nervosa.

e. 307.59, other and unspecified disorders of eating.

f. 311, depressive disorders.

g. 313.81, oppositional defiant disorder.

7. Nervous system.

a. 732.4, obstructive sleep apnea.

b. 327.26, sleep-related hypoventilation/hypoxemia in conditions classifiable elsewhere.

c. 780.51, insomnia with sleep apnea.

d. 780.52, insomnia, unspecified.

e. 780.54, hypersomnia.

f. 780.57, unspecified sleep apnea.

g. 780.71, chronic fatigue syndrome.

8. Skin and subcutaneous tissue.

a. 701.2, Acquired acanthosis nigricans.

9. Respiratory.

a. Asthma.

• 786.05, shortness of breath.

10. Orthopedic.

a. Hip pain.

b. Knee pain.

c. Blount's disease.

d. SCIFES.

III. OBESITY ASSESSMENT

A. Vital signs and BMI calculation.

1. Obesity is a chronic condition involving an excess of body fat. It is often defined by body mass index (BMI). BMI varies in children by age and sex. BMI for age is weight in kilograms divided by height in meters squared (kg/m2).

a. Measure height.

b. Measure weight.

c. Calculate BMI and plot on gender-specific growth chart (see 2000 CDC Growth Charts: www.cdc.gov/growthcharts/).

• 85th-94th percentile for BMI is overweight and in need of consistent education on healthy eating and physical activity.

• BMI at 95th percentile or above is obese and in need of intervention based on severity of obesity.

d. BMI should be tracked at each well care visit.

e. BMI calculators are available online (see: www.statcoder.com/growthcharts.htm; and for parents: www.nhlbisupport.com/bmi).

f. Blood pressure, (correct cuff size) documented and compared to norms for age and sex, hypertension if systolic or diastolic blood pressure higher than 95th percentile for age, gender, and height on more than three occasions.

B. Patient history of current habits.

1. Nutrition.

a. 24-hour recall.

b. Fruits and vegetables.

c. Sugar-sweetened beverages.

d. Milk–type and quantity.

e. Noncaloric beverages.

f. Snacking–types and quantity.

g. Portion size.

h. Eat at home or eat out in sit-down restaurants or fast food–how often.

i. Eat breakfast, lunch, and dinner or skip meals.

j. Eat at table or in front of TV; eat alone or with other family members.

k. Binge eating.

2. Physical activity.

a. Assess family's physical activity habits.

b. Type and quantity.

c. Access to gym, playground, boys or girls club.

d. Physical education.

e. Organized sports.

f. Walking to school or in daily activities.

g. Any shortness of breath with activity.

h. Joint pain, knee, hip, feet, type of footwear, any use of orthotics.

3. Screen time.

a. Type and quantity.

b. TV/computer in room.

C. Review of systems.

1. Constitutional; sleep habits, fatigue, and lethargy.

2. Respiratory; snoring, wheezing, coughing, difficulty breathing.

3. Cardiovascular; chest pain.

4. Gastrointestinal; abdominal, pain, vomiting, constipation.

5. Skin; striae.

6. Neurologic; developmental delay, headache.

7. Genitourinary; menarche, oligo/amenorrhea.

D. Family history.

1. Obesity.

2. Diabetes.

3. Hypertension.

4. Cardiovascular disease.

5. Depression.

6. Polycystic ovarian syndrome.

E. Social history.

1. School/daycare.

2. Who lives at home?

3. Who helps parent?

4. Are there multiple caregivers?

F. Past medical history.

1. Birth weight–IUGR/LGA.

2. Complications at birth.

3. Mental health.

a. Anxiety, school avoidance, social isolation.

b. Sleepiness.

c. Recent stressors.

G. Medications.

1. Neuropsychiatric medications may affect weight gain.

H. Physical exam.

1. Skin.

a. Acanthosis nigricans indicates increased risk of insulin resistance.

b. Hirsutism, acne may indicate polycystic ovary syndrome.

c. Irritation and inflammation–a complication of severe obesity.

d. Violaceous striae indicate possible Cushing's syndrome.

2. Eyes.

a. Papilledema, cranial nerve V1 paralysis–possible pseudotumor cerebri.

3. Throat.

a. Tonsillar hypertrophy–possible obstructive sleep apnea.

4. Neck.

a. Goiter may indicate hypothyroidism.

5. Chest.

a. Wheezing–possible asthma and exercise intolerance.

6. Abdomen.

a. Tenderness may indicate gastroesophageal reflux disorder, gall bladder disease, nonalcoholic fatty liver disease (NAFLD).

7. Reproductive.

a. Tanner stage–premature puberty age younger than 7 years in Caucasian girls, age younger than 6 years in African American girls, and age younger than 9.years in boys.

b. Micropenis–may be normal penis buried in fat.

c. Undescended testis/micropenis may be Prader-Willi syndrome.

8. Extremities.

a. Abnormal gait, limp, limited hip range of motion–possible slipped capital femoral epiphysis.

b. Bowing of tibia–possible Blount's disease.

c. Small hands and feet, polydactyl–possible Prader-Willi syndrome, Bardet-Biedl syndrome.

I. Laboratory tests.

1. Complete blood count (CBC).

2. Comprehensive metabolic panel (CMP).

3. Fasting lipid profile.

4. Fasting glucose.

5. Fasting insulin.

6. Hemoglobin A1C.

7. Alanine aminotranferease (ALT), aspartate aminotransferase (AST).

8. Sleep study if signs of snoring, napping, headaches, daytime sleepiness, restless sleep, and unrefreshed sleep.

J. Plan.

1. Assess family's readiness to make changes.

a. Motivational interviewing–patient-centered method for enhancing intrinsic motivation.

b. Elicit patients' and families' motivation to change.

c. Encourage patients to take responsibility for their behavior.

d. Ambivalence needs to be resolved for change to occur.

2. Goal setting.

a. Set measurable and achievable goals.

b. Use small steps and gradual change.

c. Aim for long-term healthy behaviors/lifestyle change with slow weight loss (1-2 pounds per week).

d. Focus on success, what has worked in the past.

e. Expect periods of relapse and be ready to help guide patient and family and troubleshoot situations and support return to plan in nonjudgmental way.

3. Logging of food intake.

a. Provide a journal to log the diet, with beverages, meal time, food and portion size, snacks on a daily basis. This will increase awareness of intake and has proven to show weight loss if done consistently.

4. Nutritional goals.

a. Promote three meals daily, not meal skipping, and emphasize that breakfast provides energy for the day.

b.  Increase fruit and vegetable intake; daily fruit recommendations from http://www.choosemyplate.gov/.

c.  Water and low-fat milk as main beverages; eliminate high-calorie, sugar-sweetened beverages; limit 100% fruit juice.

d.  Avoid distractions during meal time; eat as a family and not alone. This will promote good nutrition practices, increase awareness, and slow down mealtime.

e.  Provide age-appropriate information on portion size.

f.  Limit fast foods.

g.  Limit refined sugars, high-fat foods.

h.  Aim for reasonable daily target for calorie reduction and weight loss (1-2 pounds per week).

5.  Physical activity goals.

a.  Assess present activity level, both individual and family.

b.  Promote increasing activity on a daily basis, such as increased outside activity–goal is 60 minutes or more daily.

c.  Gradually increase vigorous aerobic activity as tolerated.

d.  Limit total screen time to 2 hours or less per day (TV, computer, texting, video games).

e.  Remove TV from the bedroom; keep sleeping area free of distractions.

f.  Provide free pedometers with age-appropriate goals for steps; parents may also enjoy walking with children to encourage family activity.

g. Provide information on community gyms, centers, after-school activity centers that promote increased physical activity. Look for scholarship opportunities or discounts based on family income in these centers. Promote activities provided by schools, sports, clubs, and year-round athletic activities.

6.  Subspecialist referral for comorbidities.

a. Provide referrals to orthopedics, physical therapy, or podiatrist for hip/knee pain or flat feet.

b. Promote adequate sleep, early bedtime, and waking at the same time each morning; refer for a polysomnography if snoring, unrefreshed sleep, headaches, or daytime sleepiness.

c. Refer to neurology for headaches, pseudotumor cerebri.

d. Pediatric endocrinology for type 2 diabetes, metabolic syndrome, polycystic ovarian syndrome.

e. Pediatric gastroenterology for progressive elevated ALT and AST levels and persistent stomach pain.

f. Pediatric pulmonary for sleep study and asthma.

g. Pediatric psychology for depression, anxiety, and low self-esteem, family dysfunction.

h. Medical genetics for chromosome abnormalities, Prader-Willi syndrome, fragile X, developmental delay.

7. Follow up.

a. Patients will set and reach healthy weight goals pertaining to physical fitness, activity level, and weight.

b. Patients will develop individualized health plans to encourage increased activity and decreased caloric intake.

c. Patients will participate in individual sessions, behavioral modification, and group activity sessions.

d. Patients will be responsible for keeping a food log, wearing pedometer for 24 hours, and keeping activity log.

e. BMI will be tracked at all clinical visits.

f. Incentives will be offered to encourage program compliance.

BIBLIOGRAPHY

American Academy of Pediatrics Pediatric Obesity Clinical Decision Support Chart 5201; 2008.

Barlow SE, & Dietz WH. Obesity Evaluation and Treatment: Expert Committee Recommendations. Pediatrics, 2007;102:S164.

Daniels SR, Arnett DK, & Eckel RH. Overweight in children and adolescents: Pathophysiology, consequences, prevention, and treatment. American Heart Association: Scientific Statement. 2005;111:1999-2012.

Fennoy I. Metabolic and Respiratory Co morbidities of Childhood Obesity. Pediatric Annuals. 2010;39: 140-145.

Parks E. Practical application of the nutrition recommendations for the prevention and treatment of obesity in pediatric primary care. Pediatric Annuals. 2010;39:147-153.

Riley POWER Program Tool Kit: A comprehensive weight management program designed to improve health of obese children (ages 2-18) Riley Children's Hospital, A Clarian Health Partner. NICHQ National Initiative for Children's healthcare Quality.

Schwartz RP. Motivational Interviewing (Patient-Centered Counseling) to Address Childhood Obesity. Annuals. 39:154 -158.



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