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September 2017
Coding corner: Morbid obesity
“Once morbid obesity is diagnosed and coded as such, it’s important that the diagnosis be coded correctly during each visit. To provide the best quality of care for these patients, accurate and consistent coding plays a key role in helping identify appropriate disease and care management programs for morbidly obese patients.”
— Dr. Raymond Hobbs, Blue Cross medical consultant
With obesity on the rise, it’s crucial that doctors recognize the negative effect that obesity and accompanying complications can have on their patients’ health.
“Overweight,” “obesity” and “morbid obesity” are distinct diagnoses that should be properly documented.
The Centers for Medicare & Medicaid Services includes morbid obesity (ICD-10-CM code E66.01) and its associated body mass index values (40 and above: ICD-10-CM code range Z68.41-Z68.45) in its ICD-10 Hierarchical Condition Categories for calendar year 2017. This categorization affects how providers document the condition.
Coding issues occur when the condition isn’t noted in the medical record. For example, even when height and weight measurements alone might indicate that the patient is morbidly obese, the provider must document the BMI of 40 or more — as well as comorbid conditions such as diabetes and hypertension — in the notes.
Can a BMI value of 40 with comorbid conditions and no mention of morbid obesity in the medical record be used to code for morbid obesity? The answer is no. Documentation of “morbid obesity” must be noted in the medical record to assign code E66.01. It’s important to note that BMI is a secondary code assignment; a primary diagnosis of overweight, obesity or morbid obesity must be in the documentation to submit the BMI code.
In addition, health care providers might not document morbid obesity in its early stages as they evaluate the patient over time and recommend interventions that could help reverse the trend. These may include education about how the condition can affect overall health, exercise and diet counseling.
Here are some morbid obesity coding tips:
- A coder can only code what is documented in the medical record.
- The diagnosis must be documented to its highest specificity. The BMI or complications alone can’t determine the specificity and ICD-10 code selection.
- It’s crucial to document the medical condition even after a patient has had weight loss surgery.
- Documentation is the key to coding morbid obesity.
- When the diagnosis of “overweight” or “obesity” is documented in the medical record and it’s noted the patient has a BMI of 40 or above — along with comorbid conditions affecting the patient’s overall health — the coder can only code the condition of overweight or obesity with the Z code for the BMI of 40 or above.
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 all applicable state and federal laws and regulations. | 
