News: ICD-10-CM Tips for Reporting Obesity and BMI

CDI Strategies - Volume 10, Issue 24

by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP

The diagnosis of obesity is one of the more difficult documentation matters that CDI specialists likely face. It’s a complicating factor in many areas of healthcare, and its effect on care is multifold.

According to the National Institutes of Health (NIH), morbid obesity is defined 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 comorbid conditions

High-risk comorbid conditions include the diagnoses of:

  • Body size problems precluding or severely interfering with employment, family function, and ambulation
  • Life-threatening cardiopulmonary problems (e.g., severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy)
  • Obesity-induced physical problems interfering with a normal lifestyle (e.g., joint disease treatable except for the obesity)
  • Type II diabetes

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 mental issues in addition to the obesity such as:

  • Active substance abuse
  • Bulimia nervosa
  • Severe depression
  • Socially disruptive personality disorders
  • Untreated or undertreated mental illnesses associated with psychoses

The Centers for Disease Control (CDC) states that over the last 30 years (as of 2009), obesity is now considered to be “epidemic” in the United States. For adults 60 years and older, the obesity rate is approximately 37% among men and 34% among women.

The NIH breaks down obesity into classes:

  • Class I is BMI 30–34.9 kg/m2
  • Class II is BMI 35–39.9 kg/m2
  • Class III is BMI greater than 40 kg/m2

By using the information documented in the record, coders can report 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.

Editor’s Note: This article was originally published in JustCoding. To read the full article, click here.

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