Wednesday, July 20, 2016

Coding Complications of Pregnancy: Hypertension, Pre-eclampsia, Eclampsia and ICD-10

Coding Complications of Pregnancy:  Hypertension, Pre-eclampsia, Eclampsia and ICD-10

Hypertension is dangerous during pregnancy because it may interfere with the placenta's ability to deliver oxygen and nutrition to the fetus and has also been noted to be a contributing factor in  low-birthweight babies.  Pregnant patients may have other health problems too, such as gestational diabetes,  that can contribute to the complexity of the pregnancy.  These pregnancy complication may necessitate a patient be induced for delivery prior to the “normal” timeframe of 38-40 weeks of gestation.  If induced for delivery,  the patient will be closely monitored for a vaginal, or if more complications arrise, be delivered via cesarean section.

Women with hypertension in pregnancy have a higher risk of complications such as:
·         Abruptio placentae. (Placental abruption)
·         Cerebrovascular accident. (CVA)
·         Disseminated intravascular coagulation. (DIC)

The fetus has an increased risk of:
·         Intrauterine growth restriction. (IUGR)
·         Prematurity.
·         Intrauterine death.

As you can see in the table below, ICD-10cm gives us these codes to be used when hypertension is a factor in pregnancy, childbirth and the puerperium.

O10  Pre-existing hypertension complicating pregnancy, childbirth and the puerperium
O11  Pre-existing hypertension with pre-eclampsia

O12  Gestational [pregnancy-induced] edema and proteinuria without hypertension
O13  Gestational [pregnancy-induced] hypertension without significant proteinuria

O14  Pre-eclampsia
O15  Eclampsia
O16  Unspecified maternal hypertension

As we can see, not only do coders have to choose the correct code, the providers need to give good clear documentation for the coders to choose from.   However, before we can correctly choose these codes, we need to have a good working knowledge of what the definitions are of the pregnancy hypertensive code-set.   Unfortunately , the cause of pre-eclampsia is still unknown. 

Pre-existing hypertension is defined as: 
·         a systolic blood pressure (BP) of 140 mm Hg or greater,
·         and/or a diastolic BP of 90 mm Hg or more,
·         either pre-pregnancy or  before 20 weeks

Gestational hypertension (aka pregnancy-induced hypertension)  
·         Is the development of a new hypertension diagnosis in a pregnant woman after 20 weeks gestation without the presence of protein in the urine or other signs of preeclampsia.
·         Can be considered severe when systolic blood pressure is ≥160 mmHg and/or diastolic blood pressure is ≥110 mmHg on two consecutive blood pressure measurements at least four hours apart

Preeclampsia is defined as:
·         A condition in pregnancy characterized by abrupt hypertension (a sharp rise in blood pressure),
·         Albuminuria (leakage of large amounts of the protein albumin into the urine)
·         Edema (swelling) of the hands, feet, and face
·         A headache that will not go away
·         Seeing spots or changes in eyesight
·         Pain in the upper abdomen or shoulder
·         Nausea and vomiting (in the second half of pregnancy)
·         Sudden weight gain
·         Difficulty breathing
·         Severe hypertension and signs/symptoms of end-organ injury are considered within the severe spectrum of the pre-eclampsia disease process.
o   Note:  In 2013, the American College of Obstetricians and Gynecologists (ACOG) removed proteinuria as an essential criterion for diagnosis of preeclampsia with severe features.

Eclampsia is defined as:
·         The development of grand mal seizures in a pregnant patient with diagnosed pre-eclampsia, (in the absence of other neurologic conditions that could account for the seizure activity)

HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is commonly defined as :
·         a severe form of pre-eclampsia,  OR
·         HELLP syndrome can be considered an independent disorder from pre-eclampsia based upon the providers documentation)

Preeclampsia affects 3% to 5% of all pregnancies and any pregnant woman can get preeclampsia, but studies have shown that a patient is at a higher risk of pre-eclampsia if the provider has noted any of these risk factors:

·         This is the first pregnancy
·         A family history where the patient’s mother or sister had preeclampsia or eclampsia during pregnancy
·         Patient is pregnant with a multiple gestation (eg: twins, triplets)
·         Patient is under age 20 or over age 40 at the time of pregnancy
·         The patient has a pre-existing diagnosis of high blood pressure, kidney disease, or diabetes
·         The patient has a pre-pregnancy body mass index (BMI) greater than 30 (potential obesity)
·         The patient was diagnosed with preeclampsia in a previous pregnancy

What to look for clinically – to choose the correct codes in ICD-10

Now that we are fully entrenched in ICD-10 coders will need to look for the above and verify that the provider has clearly stated the diagnosis when coding for a pregnant patient with symptoms of hypertension and/or pre-eclampsia.    If only the symptoms are noted, it is warranted to then query the physician and ask if the symptoms correlate to a specific diagnosis, or are simply “separately identifiable”  signs and symptoms.

Clinical Emergency Department Note:
HPI: 41-year female, G2P0A1, at 36 and 3/7 weeks,  presents to the Emergency room with sever headache and confusion.  Husband and mother both report that the patient has had episodes of muddled thinking for last ten days or more.  Pregnancy has been uneventful.  While in the Emergency Department, the  pt complains of bilateral pulsing headache with no visual disturbances. Headache is aggravated with any movement and has not responded to Tylenol.  Pt has had nausea x 3 days, no vomiting, but has symptoms of oliguria. Pt states “Cannot remember when I last urinated”.   ROS includes  RUQ pain.  Patient reports good fetal movement, denies contractions, vaginal bleeding, or pelvic cramping. Patient also denies dizziness, loss of coconsciousness, tremors, seizures, SOB, chest pain.   Patient denies tobacco, alcohol, or drug use.  Patient states she took Tylenol 2 hrs ago, but without relief of headache.

Physical Exam:
Vital Signs: BP 142/94, T 98.9°F, P 94, R 22. Ht: 5’ 0” Wt: 151 lb.
Well nourished, well-groomed, A&Ox3, mood distressed.
HEENT, Respiratory and Cardiac exams all normal.
Abdomen: Fundal height consistent with 36 weeks, single fetus, vertex and engaged; fetal weight ~ 2,200g, FHR 142 bpm. Fetus small for gestational age.
Musculoskeletal: Adequate muscle tone + full AROM x4. Deep tendon reflexes were 4+/4+ with sustained knee and ankle clonus.
Extremities: Generalized edema present, 3+ bilateral edema LE. No cyanosis.
Vaginal exam: Cervix fingertip dilated and 5% effaced. The vertex was presenting at 0 station. Membranes intact. Laboratory: U/A 3+ proteinuria +2 glucose

Assessment/Plan:  Severe pre-eclampsia.  Will obtain Fetal ultrasound with bio-physicial profile and fetal non-stress test to assess fetal status.  Proceed with Direct admit to Labor and Delivery unit for induction of labor.  Admission orders: called and faxed to L&D unit nurse.  Will contact patient’s primary OB to meet the patient at L&D and assume care for induction of labor in a pre-eclamptic advanced maternal age patient.


Operative Note:
Indication:   41-year-old patient that has been admitted to Labor and Delivery unit for induction of labor due to Severe pre-eclampsia.  Induction attempted with IV Pitocin, but patient failed to progress. Fetus is cephalic per bedside ultrasound, and we will proceed with low transverse c/s

Patient was prepared and draped in the usual manner.  Incision was made as noted above and carried down through the subcutaneous tissue, muscular fascia and peritoneum. Once inside the abdominal cavity, a low cervical transverse incision was made in the lower uterine segment after creating a bladder flap by both blunt and sharp dissection. With creation of the bladder flap, a transverse incision was made and the infant was delivered as a vertex. The placenta was removed and appeared normal w/3 vessel cord, cord blood was obtained. The infant was handed off to the nurses in attendance. The uterus was then exteriorized and brought out through the abdominal incision. We then closed the uterine incision in the usual manner with #1 Chromic suture in a running continuous manner. The bladder flap was inspected for hemostasis and closed with #2-0 Chromic in a running continuous manner as well. Number 0 Vicryl was used to close the fascia in a running continuous manner. The subcutaneous tissue and peritoneum were closed with #2-0 Vicryl suture in a running continuous manner. The skin was closed as noted above. Foley catheter inserted. Clear urine was noted. The sponge count was correct times 2. There were no complications.  Estimated blood loss was 600 cc.  Delivery of live male infant weighting 5 pounds 1oz having Apgar’s of 7 at one minute and 9 at five minutes.  The patient was then awakened and taken to the Recovery Room in good condition 

CPT Procedure Coding considerations for the above include:
A)     Coding and Billing for the Emergency Department visit (99281 – 99285)
B)      Coding and Billing for the Cesarean and/or Global Delivery Care by OB  (Depending on care delivered)
a.       59510    Routine obstetric care including antepartum care, cesarean delivery, and postpartum care (Global Service)
b.      59514    Cesarean delivery only;
c.       59515    Cesarean delivery only; including postpartum care

ICD10 pcs Procedure Coding Consideration
10D00Z1 Extraction, Products of Conception, Low Cervical cesarean section

ICD-10 cm Diagnosis Coding considerations include:
O14.13 Severe pre-eclampsia, third trimester
O61.0  Failed medical or unspecified induction of labor, delivered, with or without mention of antepartum condition
O09.513 Supervision of high-risk pregnancy with elderly primigravida third trimester N/A
Z3A.36  36 Weeks gestation
Z37.0 Single live birth

Coding Wrap up

In the clinical documentation by the provider, it was very well outlined and recorded to show the clinical diagnosis of severe pre-eclampsia.  As per the ICD-10cm guidelines, In coding for obstetrics, if the trimesters are known, it is to be coded, in addition to the weeks of gestation. 

When coding for this scenario in CPT, the E&M of the emergency room physician is considered “separately identifiable” from the obstetricians’ charges.  Therefore, it is appropriate to code and bill for the emergency room physician, based upon the documentation. 

When choosing the CPT code for the delivery, the coder will need to ascertain whether or not the delivery was performed as a “global” service.  If the global service was performed by the OB provider, the entire spectrum of pregnancy care (which includes; antepartum, delivery care, and postpartum care services) should be billed.   If the physician performed only the cesarean delivery and is not the global provider of service, then the cesarean only code should be billed.  This also holds true if the provider performed the cesarean and is going to provide the postpartum care too.

ICD-10pcs – the coder needs to know whether or not the cesarean was performed as a classical, low cervical, or extraperitoneal cesarean section.  In the operative note, the physician noted this was a low transverse cesarean section.  The ICD-10 tables bring us to the code 10D00Z1 Extraction, Products of Conception, Low Cervical cesarean section.

If you are not seeing all the information you need in the clinical documentation to determine if the diagnosis is “hypertension”  “pre-eclampsia”  “Eclampsia” or “HELLP” syndrome,  do not hesitate to query the provider and ask for additional clarification to be documented in the record. 

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:   

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

Tips for Coding and Documenting for Bariatric Surgery in ICD-10pcs - Inpatient

This is from my HCPro article  published June 2016
In last weeks HCPro outpatient article we addressed tips for coding in the physician office, and the challenges with that side of medicine that affects both the physician and the physician office or group practice.   In this article, we are addressing the inpatient side. 

As discussed in the outpatient article, the disease of obesity is considered a major health problem In the US.  Unfortunately, the disease process of obesity continues to be a major risk factor for the diagnoses in many other diseases such as diabetes, hypertension, sleep apnea, arthritis, and many, many more.  Obesity is also medically associated with significant morbidity and mortality risk factors when any type of surgical or operative intervention(s), or even non-surgical hospitalization is necessary.
Most medical providers define and document obesity by the measurement of body mass index (BMI). The BMI is calculated by dividing a patient's mass (kg) by his or her height (m2). A normal BMI is considered in the range of 18.5-24.9 kg/m2. A BMI of 25-29.9 kg/m2 is considered overweight. A BMI of 30 kg/m2 or greater is classified as obese; this classification is further subdivided into class I, II, or III obesity.  In ICD-10cm, obesity and BMI are now easily identifiable, and should be documented in the patients’ records when obesity is being treated as a stand-alone diagnosis, or as part of a diagnosis with other disease processes that are impacted by obesity.   The ICD-10 codes Z68.xx should be coded in addition to the diagnosis of obesity in the medical record and on your insurance claims

As we have been perfecting our ICD-10pcs coding skills with the ICD-10 tables;  Let’s take a quick look again at the basics of code construction. 

·         All ICD-10-PCS codes have seven digits, each digit representing a specific character associated with procedures.
·         Code assignment in ICD-10-PCS is a process of “constructing” the code by selecting values from the ICD-10 pcs code tables for each of the seven standard characters.
·         The first three characters identify the code table that is used to complete the remaining four characters.

The basics of bariatric ICD-10-pcs code selection
·         1: Section:  For bariatric procedures; the appropriate section is 0-Medical and Surgical.

·         2: Body System:  Bariatric procedures involve the stomach and intestines, so code tables need to be referenced from; D-Gastrointestinal System.

·         3: Root Operation:  When coding for the Root operation, in bariatric surgery, these are assigned according to the objective of the procedure.  There are standard definitions to be reviewed in ICD-10 for root operations.  When choosing the root operation, and the specific procedure that the physician is going to perform, there are three root operations that are most commonly used in bariatric coding.

1.       Bypass: Altering the root of passage for the contents of a tubular body part, eg, Roux-en-Y gastric bypass
2.       V-Restriction: Partially closing an orifice or the lumen of a tubular body part, eg, gastric banding
3.       B-Excision: Cutting out or off, without replacement, a portion of a body part, eg, sleeve gastrectomy

§  Note:  that because the procedure's objective is the defining factor in assigning the root operation, some procedures that are not associated with bariatric coding may also use the same ICD-10-PCS code.

§  Note: The physician is not expected to document using ICD-10-PCS code descriptions. It is your responsibility as a coder to determine what the physician's operative note documentation equates to in terms of ICD-10-PCS.  AHIMA has stated that coder is not required to query the physician in these circumstances.

·         4: Body Part:   In the respective ICD-10 pcs code tables the specific body part values that are available for you to choose from are for stomach, duodenum, and ileum.

·         5: Approach:  The approach used for the bariatric surgical procedures performed are:
o   Via laparotomy use 0-Open.
o   Via laparoscopy use 4-Percutaneous Endoscopic.

·         6: Device:  Interestingly in bariatric surgery, the device character is not used for surgical instruments that accomplish the procedure.  The device character is used to describe the devices that remain in the patient's body after the procedure is completed.  (eg, implanted devices) 
o   For a Gastric banding procedures, the coder will use
§  C-Extraluminal Device because the band encircles the lumen of the stomach from the outside.
o   If you are coding other bariatric procedures,
§   Z-No Device is most common choice when coding.

·         7: Qualifier: Qualifiers add further information to the ICD-10pcs code choice.
o   For therapeutic procedures, the most common qualifier is Z-No Qualifier.
o   For bypass procedures, the qualifier identifies the body part being bypassed to
§  eg…  re-routing the digestive tract from the stomach directly to the ileum you would use the  uses the qualifier B-Ileum.

Operative Report #1 

Laparoscopic (Lap-Band) gastric band placement
The procedure consisted of laparoscopic placement of a gastric band (Lap-Band System), creating a proximal 15-mL pouch at the cardia.
The patient was positioned in an elevated recumbent position. The video monitor was located beyond the patient’s right shoulder.  Pneumoperitoneum was created using a Palmer-Veress needle. The 10-mm optical trocar was inserted first, 10 cm below the xiphoid notch. Then, three 10-mm cannulas were placed under the rib margin.  The fourth cannula on the left had a larger diameter (18 mm) to allow the introduction of the band. All cannulas were then shifted to the left when preoperative (re-review) ultrasound revealed an enlarged left liver lobe (>15 cm high) in the patient. A 10-mm liver retractor was inserted through a paraxiphoid cannula and the left lobe was elevated to expose the cardiac area and the diaphragmatic crus.
Gastric dissection started at the angle of the cardia by division of the phrenogastric ligament. We proceeded with the lap band procedure with a pars flaccida approach on the right side.  Dissection on the left side was identical to that performed on the right. Over the lesser omentum, we opened the peritoneal sheet close to the edge of the right crus, then gradually created a retrogastric tunnel reaching the left crus and the phrenogastric ligament. Thus avoiding tthe use of a balloon.  The band was secured by an anterior gastrogastric valve using four nonabsorbable seromuscular stitches.  This covered the anterior part of the band completely. A methylene blue dye test was carried out with no leaks detected.  The subcutaneous port components were then placed and verified as per our pre-operative marking.   Patient was taken to PACU in good condition. 
Coding Choices:
ICD-10pcs code: 0DV64CZ
Previous ICD-9 Vol 3:  44.95
CPT code: CPT Code: 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components

Now as we look at some of the coding options for an “open” and “laparoscopic’ bypass procedure you will note the same table is used, but they are 2 completely different codes as one is an “open procedure” the other is “laparoscopic”

• Gastric bypass from stomach to ileum, performed via laparotomy
0D160ZB Bypass stomach to ileum, open approach

• Gastric bypass from stomach to jejunum, performed via laparoscopy
0D164ZA Bypass stomach to jejunum, percutaneous endoscopic approach

Diagnosis coding for bariatric medicine and bariatric surgery requires not only the definitions of the obesity, but notation of BMI.  Most often the obesity diagnosis will remain as the primary reason for bariatric surgery, but any co-morbidities will also play into the DRG that will affect the reimbursement for the facility where the bariatric surgery is being performed.

According to AHIMA, they suggest including this into your medical records for the clinical documentation when referencing obesity and bariatric surgery:

• Obesity
                - Morbid (severe)
° Due to excess calories
° With alveolar hypoventilation (Pickwickian syndrome)
 - Drug Induced
° Document drug
 - Other ° Due to excess calories, familial, endocrine

• Overweight
• Body Mass Index (BMI)
• Document any associated diagnoses/conditions
o   Hypertension
o   Type II Diabetes Mellitus
o   Dyslipidemia
o   Musculoskeletal, neurological or body size problems precluding or severely impairing quality of life (employment, family function or ambulation)
o   Life-threatening Cardiopulmonary Problems (sleep apnea, obesity-hypoventilations syndrome or obesity-related cardiomyopathy)
o   Coronary Artery Disease
o   Obesity-Related Cardiomyopathy
As we can see from this table below of 2016 “estimated” DRG’s and reimbursements for facilities, a bariatric surgery can be very lucrative for your facility.  The DRG assignments will need to be carefully reviewed when coding out bariatric surgery to obtain the highest appropriate DRG’s. 

Currently, there has been an increase in private insurance companies covering bariatric surgical procedures if the patient meets the standard criteria for morbid obesity.  However, some carriers may not cover it at all, and it may be a self-pay only option for the patient.  Medicare has been one of the primary payers that have approved bariatric surgery, with the resulting off-set of better health for the patient, and a reduced risk of long-term medical complications from the co-morbidities.

Medical necessity plays a huge part in a patient being able to undergo a bariatric surgery.  If the patient is morbidly obese and has a body mass index (BMI) of 40 or higher an insurance carrier is more likely to approve or pre-authorize a surgery.  Another criteria that may be imposed, is if the patient has been obese for the past five years or longer, and has
attempted, under a physician’s care;  other methods of weight loss for at least two years. These may include behavior modification, psychological evaluations, in addition to specifically proven medically regulated diets such as “Optifast”  “Medifast”  or even drug therapies such as orlistat (Xenical), lorcaserin (Belviq), phentermine and topiramate (Qsymia), buproprion and naltrexone (Contrave), and liraglutide (Saxenda).  If the patient has comorbidities such as hypertension, diabetes, sleep apnea, degenerative arthritis, and heart disease that increase the consideration of medical necessity for surgery.

In addition there are some patients in which they would not qualify for bariatric surgery. Absolute contraindications to bariatric surgery are active substance abuse and psychiatric personality disorders.  In addition, previous abdominal surgeries or previous bariatric procedures that were ineffective are not necessarily contraindications, but the patient may not be approved for more extensive bariatric surgery.  Some studies have borne out that procedures which alter the size of the stomach and restrict food intake, may exacerbate some eating disorder.  If the patient has a history of a true anorexia nervosa, they are generally considered not eligible for bariatric surgery.
As a coder, good documentation from your providers in the H&P  help ensure you are able to clearly code and report the operative session(s), with the diagnosis of obesity and all additional diagnoses that are impacted by the obesity (medical necessity).  All of these criteria go hand in hand with good quality patient care and correct coding and billing of claims. By working closely with your providers, you can ensure good clean claims, and reduce your overall risk of audit inquiry and financial recoupment of paid claim services.

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: