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.
•
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
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.
•
Preeclampsia:
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.
•
Stillbirth:
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 webbservices.lori@gmail.com or you can also find current
coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
*******************************************************************************************************
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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