Q&A: BMI and obesity denials

Q: When faced with a body mass index (BMI) denial, I have used the following Coding Clinic references with no luck:

• Coding Clinic, Fourth Quarter, 2018, p. 77: "obesity and morbid obesity are always clinically significant and reportable when documented by the provider. In addition, if documented the BMI code may be coded in addition to the obesity or morbid obesity code."
• Coding Clinic, Third Quarter, 2011, p. 4: "individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to person of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider."

What recommendations do you have for these BMI denials moving forward?

A: To start, make sure to communicate with providers that if they feel a diagnosis related to BMI is significant, they need to provide education or counseling to their patient regarding that diagnosis and make sure that counseling is documented in the patient record. For example, education on lifestyle modification, dietary counseling, or a nutrition consultation are all appropriate and should be documented.

If providers add more detail when diagnosing the patient as to how the diagnosis plays a role in the current admission, it helps capture medical necessity and may reduce the chance of a denial. This is a great opportunity for the CDI team to offer physician education on this topic, whether that be in a group session, one-on-one as needed, or through tip sheets.  

Even if you’re still having no luck with overturning these BMI/obesity denials, you should still query the provider for more details and code the condition per the Official Guidelines for Coding and Reporting and Coding Clinic guidance. Ultimately, focus your attentions on working with providers to improve their documentation for including why the diagnosis plays a role in the admission and adding any counseling related to lifestyle changes to the notes section.

Editor’s note: This question and answer were adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.