Coding Corner: Documentation is key when coding morbid obesity

With an increasing number of Americans becoming overweight or suffering from obesity, it’s important for physicians to recognize the degree to which obesity — and its ever-present complications — negatively impacts patient health.

Overweight, obesity and morbid obesity are distinct diagnoses that must be properly documented.

The Centers for Medicare & Medicaid Services includes morbid obesity (ICD-9-CM code 278.01) and its associated body mass index values (40 and above, ICD-9-CM code range; V85.41-V85.45) in its 2014 Hierarchical Condition Categories Model. This categorization impacts the way providers should document the condition.

From a coding perspective, documentation of morbid obesity in the medical record makes it easier to assign code 278.01 with an associated V code. A problem may arise when obesity is documented in the medical record, but evidence indicates that the patient is morbidly obese. For example, the patient has a body mass index of 40 with co-morbid conditions.
                                                                                       
Can a BMI value of 40 with co-morbid conditions be used to validate the HCC Model for morbid obesity when there is a different diagnosis? The answer is yes. Consider the following guidelines for making a morbid obesity diagnosis:

• Patients with a BMI greater than 35 who are seen with co-morbid conditions such as osteoarthritis, sleep apnea, diabetes, coronary artery disease, hypertension, hyperlipidemia and gastroesophageal reflux disease
• Patients with a BMI equal to or above 40

According to Dr. Laurrie Knight, associate medical director for Blue Cross Blue Shield of Michigan, you should capture all of the medical complications that are associated with an obesity diagnosis. These may include sleep apnea, uncontrolled diabetes, hypertension and hyperlipidemia, among others. “This will prompt you to define and document the specific clinical condition, such as morbid obesity,” she said.

The BMI value is one of the key elements to consider when assessing morbid obesity, Dr. Knight added. “Clinical complications should also be evaluated and treated,” she said. “Sometimes multiple interventions are required to evaluate and identify a clinical condition like morbid obesity. Observing the impact of weight on other medical conditions is often a clear indicator.”

A provider may recommend several interventions that could include a dietician, incorporating an exercise regiment and education about managing other co-morbidities that can impact the total health of the patient.

“Morbid obesity may not be documented early in the year as you may opt to evaluate the patient over time,” Dr. Knight continued. “However, once you’ve determined the patient to be morbidly obese, and you code it as such, the diagnosis must continue to be coded as morbid obesity on subsequent visits.”

Since documentation is key to coding morbid obesity, a coder must review the medical record thoroughly when obesity is documented with a BMI of 40 or above, with co-morbid conditions affecting the patient’s overall health. In such a situation, a code for the BMI (the same HCC as morbid obesity) should be used to support morbid obesity.

For more information, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.