Q&A: UHDDS requirements for obesity

Q: Does your facility currently abide by any policies when it comes to coding ‘obesity’ and/or ‘morbid obesity’ in terms of requirements for the provider to document how the diagnosis has met the Uniform Hospital Discharge Data Set (UHDDS) definition of ‘monitoring, evaluating, assessing,’ etc.? For example, if a provider only lists the diagnosis in progress notes or the discharge summary and doesn’t elaborate on how it has impacted patient stay or was monitored (i.e., CO2 monitoring, diet and counseling), would the coders pick up the diagnosis without additional documentation?

A: Coders usually do code the diagnosis, as facilities usually follow The Coding Clinic on obesity/morbid which states that only body mass index (BMI) is required. The UHDDS requirements are met as the documentation is “assessing and stating the condition and measuring with BMI.” Often, you can reference this Coding Clinic when appealing a denial for obesity with a stated BMI in the record.

Sometimes, however, payers will argue that the BMI must meet the UHDDS definition of “other diagnosis.” In an appeal, one can state that the BMI is assigned to measure and quantify the severity of the obesity and supports the additional time and assistance required to care for the obese patient. This article, for instance, which describes its impact on the delivery of nursing care as well as body systems, can be included as a citation in your appeal letter.

CDI professionals should also focus on educating providers on this subject, reminding them that they are usually discussing weight and how that impacts a patient’s health, so it’s important to document it and take credit.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council.