Wednesday, July 20, 2016

Diagnosis Coding for Obesity, BMI, when noted in the clinical record

Diagnosis Coding for Obesity, BMI, when noted in the clinical record
May 20, 2016

As a coder, we are faced with the challenges of reporting all diagnoses held within the medical record that the providers are currently addressing during an encounter with the patient.  The diagnosis of obesity is one of those difficult coding issues.  Obesity is a complicating factor in many areas of health care, and its effect upon care is multifold.    According to the National Institutes of Health (NIH), they define morbid obesity as:
·         Being 100 pounds or more above your ideal body weight.
·         Having a Body Mass Index (BMI) of 40 or greater.
·         Having a BMI of 35 or greater and one or more co-morbid condition.

High-risk comorbid conditions include the diagnoses of; Type 2 diabetes, life-threatening cardiopulmonary problems (egg, severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy), obesity-induced physical problems interfering with a normal lifestyle (e.g., joint disease treatable but for the obesity), and body size problems precluding or severely interfering with employment, family function, and ambulation.

In addition, mental status can also play a part in a patients’ obesity.  Mental status is a difficult diagnosis in and of itself, but can be another diagnosis that will need to be addressed if the physician notes the mental issues such as; severe depression, untreated or undertreated mental illnesses associated with psychoses, active substance abuse, bulimia nervosa, and socially disruptive personality disorders in addition to the obesity.   The Centers for Disease Control (CDC) states that over the last 30 years (as of 2009) that obesity is now considered to be “epidemic” in the United States and in adults 60 years and older is approximately 37% and 34% among women.  

The NIH breaks down obesity into “classes”
Class I Obesity = BMI 30.0 – 34.9 kg/m2
Class II Obesity = BMI 35.0 – 39.9 kg/m2
Class III Obesity = BMI ≥ 40 kg/m2

As a coder, by utilizing the information documented in the record, we can code the BMI from a dietitian's note, or from the physician’s documentation.  However, if the numeric BMI falls into the “class” status we can report and code this as a Class I, II, or III obesity state.  The obesity documentation still has to be clearly defined within the medical record.  With that, there should be a correlation from the physician to support the obesity code assignment, and how that is currently impacting the patients’ current care and ongoing plan.

The next coding challenge to coding of an obesity diagnosis is the notation of the word “morbid” obesity.   As we know from the NIH, the definition of such is defined, yet many physicians note in the record the words “patient is morbidly obese” but do not include any further information or documentation for the coder to adequately code the obesity diagnosis correctly for that particular patient.  A patient may not have all the criteria for being “morbidly obese” according to the NIH guideline, however, a physician may document that the patient is “morbidly obese” in the medical record.   If the documentation of an obesity diagnosis is a pertinent part of that patients’ care or reason for their medical encounter; the coder is obligated to record the diagnosis accurately and may need to query the provider and ask for clarification or additional information to clearly support the “morbidly obese” diagnosis.  In addition, Coding Clinic, fourth quarter 2005, stated that coders could code BMI based on notes from dietitians, but we should still be diligent in having this information corroborated by the physician in the record too. 

AHIMA has given us a quick tool to use when asking the physician to clarify a diagnosis related to obesity.  In the ICD10cm changes for codes; the listing below helps us give clarity to the physicians, to document what we need to have to clearly report an obesity diagnosis correctly.  In addition, a BMI only identifies the ratio of height to weight and there may be outside factors or other reasons that can alter a BMI “number, such as highly muscular people, pregnant or lactating women.  It is not appropriate to assume or make the correlation that someone is diagnostically obese from a high BMI nor considered diagnostically underweight from a low BMI.

Morbid (severe)
° Due to excess calories
° With alveolar hypoventilation (Pickwickian syndrome)
Drug Induced
° Document drug
° Due to excess calories, familial, endocrine
        Body Mass Index (BMI)
        Document any associated diagnoses/conditions

From a coding perspective, documentation to support a diagnosis of overweight, obesity, and morbid obesity, obesity, should be clearly defined by the physician.  This documentation may include:

Ø  Diet discussed
Ø  Exercise encouraged
Ø  Gastric bypass surgery consult
Ø  Diet medication
Ø  Dietician referral and/or counseling
Ø  Weight loss program (i.e. gym membership)
Ø  Food log
Ø  Physiatrist referral

Obesity and Pregnancy

In April 2016, the American Congress of Obstetricians and Gynecologists (ACOG) defined what they consider obesity to be, and they closely follow the NIH guidelines.  ACOG defines the term “overweight” as having a body mass index (BMI) of 25–29.9.; and define the term “obesity” as having a BMI of 30 or greater.    ACOG has also noted that within the general category of obesity, there are three levels of “risk” go hand in hand with an increasing BMI:

        Lowest risk is a BMI of 30–34.9.
        Medium risk is a BMI of 35.0–39.9.
        Highest risk is a BMI of 40 or greater

ACOG has also confirmed that obesity during pregnancy puts the pregnant female at risk for several serious health problems such as:

        Gestational diabetes:
o   Gestational diabetes that is first diagnosed during pregnancy and can increase the risk of having a cesarean delivery.
o   Women who have had gestational diabetes also have a higher risk of having diabetes in the future, as do their children.
o   Obese women should be screened for gestational diabetes early in pregnancy and also may be screened later in pregnancy as well.

o   Preeclampsia is a high blood pressure disorder that can occur during pregnancy or after pregnancy.
o   It is a serious illness that affects a woman’s entire body.
o   The kidneys and liver may fail.
o   Preeclampsia can lead to seizures, a condition called eclampsia.
o   In rare cases, stroke can occur.
o   Severe cases need emergency treatment to avoid these complications.
o   The baby may need to be delivered early.

        Sleep apnea: 
o   Sleep Apnea is a condition in which a person stops breathing for short periods during sleep.
o   Sleep apnea is associated with obesity.
o   During pregnancy, sleep apnea not only can cause fatigue but also increases the risk of high blood pressure, preeclampsia, eclampsia, and heart and lung disorders.

        Pregnancy loss—Obese women have an increased risk of pregnancy loss (miscarriage) compared with women of normal weight.

        Birth defects—Babies born to obese women have an increased risk of having birth defects, such as heart defects and neural tube defects.

        Problems with diagnostic tests:
o   Obesity increases the difficulty to visualize and review fetal anatomy on an ultrasound exam.
o   Obesity increases the difficulty to accurately assess the fetal heart rate and/or stress levels during labor

        Macrosomia (a condition in which the baby is larger than normal)
o   Macrosomia can increase the risk of the baby being injured during birth. (e.g. a shoulder dystocia)
o   Macrosomia also increases the risk of cesarean delivery.
o   Infants born with too much body fat have a greater chance of being obese later in life.

        Preterm birth:
o   Problems associated with a woman’s obesity, such as preeclampsia, may lead to a medically indicated preterm birth. (Pre-term birth or pre-term medically necessary induction of labor for a medical reason)
o   Preterm babies are not as fully developed as babies who are born after 39 weeks of pregnancy.
o   Preterm babies have an increased risk of short-term and long-term health problems.

o   The higher the woman’s BMI, the greater the risk of stillbirth.

ICD-10cm Diagnosis Code Changes; BMI reporting

In the ICD-10cm 2016 code set, the codes currently reflect the “new” choices that coders have when reviewing correct coding for “obesity”.   In addition, ICD-10cm now includes codes for obesity that is complicating a pregnancy.   The verbiage “complicating a pregnancy” is critical when determining the correct diagnosis code.  The physician will need do have documented whether the obesity is truly complicating the pregnancy, or if the obesity is simply a status/current state and the patient is incidentally pregnant, and as a coder we cannot assume that correlation.  It is important to remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. 

When coding obesity as a diagnosis, if the BMI is documented in the record, be sure to add that in to your list of diagnoses.  Many insurance carriers are requesting the BMI to be added in conjunction with the obesity codes.  If the patient has presented for an encounter that is in regard to weight management, in coordination with a co-morbid condition be sure to code for all diagnostic co-morbidities.

When sequencing diagnoses for obesity, unfortunately the majority of health insurance plans will not pay for a claim if a code for obesity is listed as the primary diagnosis.   When sequencing obesity codes, review if the patient has other health complaints, such as type II diabetes or heart disease.  If this is the case, and the other health complaints are the primary diagnosis reason for the encounter with obesity as a secondary or tertiary diagnosis this sequencing would be appropriate. 

As a coder, it is your job to confirm the documentation to substantiate what is the primary, secondary and/or tertiary diagnoses are, and that they are clearly reflected in the medical record documentation.   Do not sequence other diagnosis codes before the obesity diagnosis in order to get reimbursed for the claim, especially if the patient is solely there for advice and/or concerns related to their obesity diagnosis. 

In a best practice situation, if the patient is seen for nutritional counseling or consultation with the diabetic educator in regard to their obesity diagnosis, and the patient does not have insurance coverage, inform the patient up-front, and have an ABN signed, or collect at the time of service.  

For drug-induced obesity, documentation should clearly identify the drug that is causing the obesity.  Coding guidelines instruct the coder to include an additional code to identify the drug causing the obesity, when known. This will result in the selection of a code from the range T36–T50, which should be sequenced after the obesity code.

In scenario #1, it is appropriate to code the diabetes diagnosis as primary; however, in scenario #2 the obesity is the primary diagnosis. 

Case Example #1: A female patient with type II diabetes without complications presents to the office for nutritional counseling.  She is 32 years old and was recently diagnosed with DMII, and is worried about her health.  She is morbidly obese and admits that she overeats. Her BMI is 36.

ICD-10cm Codes:
o   E11.9, Type 2 diabetes mellitus without complications
o   E66.01, Morbid (severe) obesity due to excess calories
o   Z71.3, Dietary counseling and surveillance
o   Z68.36, Body mass index (BMI) 36.0-36.9, adult

Case Example #2:  A female patient with severe allergies, due to the steroid Decadron, presents to the office today for nutritional counseling in regard to her weight gain from the steroid.  She is no longer on the steroid and discontinued two months ago.   She is 32 years old and had been on the steroid for 60 days with a 30 day taper.   She is worried about her 15 pound weight gain.  In addition, pt.’s weight was stable at 155 prior to the Decadron. Her weight today is 170 Her BMI is 30.

ICD-10cm Codes:
o   E66.1, Drug Induced Obesity
o   T38.OX5S Adverse effect of glucocorticoids and synthetic analogues sequela
o   Z71.3, Dietary counseling and surveillance
o   Z68.30, Body mass index (BMI) 30.0-30.9, adult

Case Example #3:  Pt is admitted to the L&D unit for extreme obesity with a mild pre-eclampsia to ensure fetal wellbeing.  Pt is currently 37 weeks plus 2 days.  Fetal presentation is complete breech. Weight 165 lbs., height 149.86cm, her calculated BMI is 48, category III Obesity.  Due to extreme obesity in pregnancy, twice daily NST’s to be performed as part of the clinical management to ensure stable fetal status and will observe the mild preeclampsia.  Coordinate care with dietician; Blood Glucose (non-fasting) was 96.  No current indication of Gestational Diabetes. Continue management for mild preeclampsia and consider induction upon NST reviews and pre-eclampsia progression.

ICD-10cm Codes:
o   O14.03      Mild to moderate pre-eclampsia, third trimester
o   O99.213    Obesity complicating pregnancy, third trimester
o   Z3A.37     37 weeks gestation of pregnancy
o   O32.1xx1  Maternal care for breech presentation
o   Z71.3         Dietary counseling and surveillance
o   Z68.41       Body mass index (BMI) 40.0-44.9, adult

Final thoughts – wrap it up neatly

As a coder, the correct diagnosing and sequencing of obesity and obesity complications is an obligation that you must take seriously when applying codes to the patients’ medical record.  An inadvertent error of a diagnosis of obesity can have multiple long-range affects to the patient’s current and on-going care.  If records are reviewed, and an incorrect diagnosis of obesity or an incorrect BMI documentation is in the record, this may preclude a patient from obtaining, medial or life insurance, and even possibly affect their financial status when obtaining a loan or monetary transactions.  Some employers even require a patient to disclose medical information prior and/or post hire.  

Correct clinical documentation in regard to obesity needs to be clear, concise and show disease correlation when appropriate.  If those items are not readily interpreted within the record, query the provider to provide clarity.   Full listings of all obesity codes are contained in the ICD-10cm code set as are the formal coding guidelines.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:  

Below is the current listing of the ICD-10cm code set for obesity and overweight coding:

Overweight, obesity and other hyperalimentation (E65-E68)
E65 Localized adiposity Fat pad

E66 Overweight and obesity Code first obesity complicating pregnancy, childbirth and the puerperium, if applicable (O99.21-)
Use additional code to identify body mass index (BMI), if known (Z68.-)
Excludes1: adiposogenital dystrophy (E23.6) lipomatosis NOS (E88.2) lipomatosis dolorosa [Dercum] (E88.2) Prader-Willi syndrome (Q87.1)

E66.0 Obesity due to excess calories
E66.01 Morbid (severe) obesity due to excess calories
Excludes1: morbid (severe) obesity with alveolar hypoventilation (E66.2)
E66.09 Other obesity due to excess calories
E66.1 Drug-induced obesity
Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

E66.2 Morbid (severe) obesity with alveolar hypoventilation Pickwickian syndrome
E66.3 Overweight
E66.8 Other obesity
E66.9 Obesity, unspecified Obesity NOS

Pregnancy Obesity Codes
O99.2 Endocrine, nutritional and metabolic diseases complicating pregnancy, childbirth and the puerperium
O99.21 Obesity complicating pregnancy, childbirth, and the puerperium
O99.210 Obesity complicating pregnancy, unspecified trimester
O99.211 Obesity complicating pregnancy, first trimester
O99.212 Obesity complicating pregnancy, second trimester
O99.213 Obesity complicating pregnancy, third trimester
O99.214 Obesity complicating childbirth
O99.215 Obesity complicating the puerperium

Body mass index [BMI] Z68- >
Applicable To Kilograms per meters squared
Note:  BMI adult codes are for use for persons 21 years of age or older BMI pediatric codes are for use for persons 2-20 years of age. These percentiles are based on the growth charts published by the Centers for Disease Control and Prevention (CDC)

 Z68 Body mass index [BMI]
Z68.1 Body mass index (BMI) 19 or less, adult

Z68.2 Body mass index (BMI) 20-29, adult
Z68.20 Body mass index (BMI) 20.0-20.9, adult
Z68.21 Body mass index (BMI) 21.0-21.9, adult
Z68.22 Body mass index (BMI) 22.0-22.9, adult
Z68.23 Body mass index (BMI) 23.0-23.9, adult
Z68.24 Body mass index (BMI) 24.0-24.9, adult
Z68.25 Body mass index (BMI) 25.0-25.9, adult
Z68.26 Body mass index (BMI) 26.0-26.9, adult
Z68.27 Body mass index (BMI) 27.0-27.9, adult
Z68.28 Body mass index (BMI) 28.0-28.9, adult
Z68.29 Body mass index (BMI) 29.0-29.9, adult

 Z68.3 Body mass index (BMI) 30-39, adult
Z68.30 Body mass index (BMI) 30.0-30.9, adult
Z68.31 Body mass index (BMI) 31.0-31.9, adult
Z68.32 Body mass index (BMI) 32.0-32.9, adult
Z68.33 Body mass index (BMI) 33.0-33.9, adult
Z68.34 Body mass index (BMI) 34.0-34.9, adult
Z68.35 Body mass index (BMI) 35.0-35.9, adult
Z68.36 Body mass index (BMI) 36.0-36.9, adult
Z68.37 Body mass index (BMI) 37.0-37.9, adult
Z68.38 Body mass index (BMI) 38.0-38.9, adult
Z68.39 Body mass index (BMI) 39.0-39.9, adult

 Z68.4 Body mass index (BMI) 40 or greater, adult
Z68.41 Body mass index (BMI) 40.0-44.9, adult
Z68.42 Body mass index (BMI) 45.0-49.9, adult
Z68.43 Body mass index (BMI) 50-59.9 , adult
Z68.44 Body mass index (BMI) 60.0-69.9, adult
Z68.45 Body mass index (BMI) 70 or greater, adult

Z68.5 Body mass index (BMI) pediatric
Z68.51 …… less than 5th percentile for age
Z68.52 …… 5th percentile to less than 85th percentile for age
Z68.53 …… 85th percentile to less than 95th percentile for age
Z68.54 …… greater than or equal to 95th percentile for age

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