1️⃣ Initial Visit

  • Vitals Signs
    • Obtain and record height and weight at every visit in the vital signs section.
    • Calculate and document BMI.
    • Exception: If the patient screens positive for an eating disorder or has a prior diagnosis of an eating disorder, do not ask about height/weight at every visit.
  • Comprehensive HPI
    • Weight Journey:
      • Highest adult weight? Circumstances (age, emotional health, significant events)?
      • Lowest adult weight? Circumstances?
      • Triggers for weight gain?
      • Motivation for weight loss?
      • Support network?
      • Adverse childhood experiences?
      • Previous weight loss attempts (programs, surgery, medications)?
      • Has the patient tried diet and exercise for >6 months?
  • Dietary Assessment:
    • Typical breakfast, lunch, dinner.
    • Food habits and preferences.
    • Beverage choices and water intake.
    • Food cravings.
    • Snacking/grazing habits.
    • Meal timing.
    • Food allergies.
    • Eating with distractions?
    • Fast food frequency.
  • Physical Activity:
    • Formal exercise (type, frequency, intensity, duration).
    • Favorite activities.
    • Equipment access.
    • Barriers to exercise.
  • Screening:
    • Has the patient had an Annual Wellness Exam (AWE) in the last 12 months?
    • Has labwork (CBC, CMP, lipids, A1c, TSH) been completed in the last 6 months?
    • Personal/family history of medullary thyroid cancer or MEN 2? (GLP-1 contraindication)
    • History of pancreatitis? (GLP-1 caution)
    • Female patients: Menstrual history.
  • Goals: Patient’s specific weight loss goals.
  • General Medical History: PMH, PSH, FMH, SocHx, current medications, drug allergies, chronic conditions.

 

🎯 Plan

  • Schedule a second visit as a video annual wellness visit if the patient has not had an annual physical in the last 12 months.
  • Review and update medical history during the annual wellness visit.

 

🔁 Follow-Up Structure

  • First Follow-Up (1-Month)
    • Assess for early changes (energy, clothing fit) even if weight is unchanged.
    • Review adherence to nutrition and activity plans.
    • Address barriers and reinforce motivation.
  • Recurrent Follow-Ups
    • Every 1 month for new medication changes or active titration.
    • Every 3 months for stable patients.
  • At Each Follow-Up
    • HPI:
      • Starting BMI (with date)
      • Current BMI
      • Current nutrition plan
      • Current exercise plan
    • Medication Review:
      • Current medication plan
      • Duration/efficacy
      • Side effects
    • Behavioral Health:
      • Therapist involvement (if any)
      • Registered dietician involvement (if any)
    • Adjust plan as needed based on progress, side effects, and patient feedback.

 

➤ Referral Out

  • Eating Disorders:
    • Patients who screen positive for a possible eating disorder should be referred out for specialized care (self-referral to an eating disorder center or psychiatrist).
  • Unstable Mental Health:
    • Patients with unstable mental health should have these needs addressed first. This may be managed at Circle Medical or referred to psychiatry if the mental health needs are complex.
  • Active Substance Abuse:
    • Patients with active substance abuse (e.g., alcoholism) should address substance use first before initiating a weight loss program.

 

🔢 Overweight and Obesity Coding (E66)

  • Begin with coding the complications (rather than a body mass index code), such as obesity complicating pregnancy, childbirth, and the puerperium, if applicable (O99.21-).
  • Do not use E66.0 (Obesity due to excess calories) as it is a non-billable code.
  • Use the following codes as appropriate:
    • 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
  • Add any other health conditions impacted by obesity, such as:
    • I10 – Hypertension
    • R73.9 – Hyperglycemia
    • E11.x – Type 2 diabetes
    • R73.09 – Prediabetes
    • E88.81 – Metabolic syndrome
    • G47.x – Sleep apnea
    • E78.5 – Hyperlipidemia
    • K76.0 – NAFLD
    • M17.9 – Osteoarthritis of knees (weight-bearing joints)

 

✨ Special Considerations

  • GLP-1 Agonists: Contraindicated in patients with personal/family history of medullary thyroid cancer or MEN 2. Use caution in patients with history of pancreatitis.
  • Eating Disorders: Avoid routine weight checks; focus on behavioral and psychological support.
  • Lab Monitoring: Repeat labs as clinically indicated, especially with medication changes.

 

✔ Documentation Checklist

  • Height, weight, BMI (unless eating disorder)
  • Detailed HPI (weight journey, diet, activity, goals)
  • PMH, PSH, FMH, SocHx, medications, allergies
  • Labs and screening status
  • Plan for follow-up and referrals (dietician, therapist, bariatric surgery, etc.)
  • Appropriate ICD-10 coding for obesity/overweight and related comorbidities

 

📚 Patient Education

  • Set realistic expectations: Initial weight loss may not be reflected on the scale; focus on energy and non-scale victories.
  • Encourage self-monitoring (food/activity logs, wearable devices).
  • Provide resources for nutrition, physical activity, and behavioral support.