RE: [EXTERNAL] RE:Morbid Obesity along with joint replacements
Any auditor must comply with the Official Guidelines governing all that function in this domain. The Coding Clinic below states clearly that Obesity is ALWAYS clinically significant and reportable.
I would include this reference to anyone questioning the coding of morbid obesity.
IMO, the rationale for always considering morbid obesity significant is self-evident.
VOLUME 28 THIRD QUARTER
NUMBER 3 2011, Page 4
Clinical Significance of Obesity
Question: If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only without any additional documentation to support clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance such as evaluation, treatment, increased monitoring, or increased nursing care, etc., for this condition.
Answer: Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented. Refer to Coding Clinic, Third Quarter 2007, pages 13-14, for additional information on coding chronic conditions.
Coding advice or code assignments contained in this issue effective with discharges September 23, 2011.
Paul Evans, RHIA, CCS, CCS-P, CCDS
I would include this reference to anyone questioning the coding of morbid obesity.
IMO, the rationale for always considering morbid obesity significant is self-evident.
VOLUME 28 THIRD QUARTER
NUMBER 3 2011, Page 4
Clinical Significance of Obesity
Question: If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only without any additional documentation to support clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance such as evaluation, treatment, increased monitoring, or increased nursing care, etc., for this condition.
Answer: Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented. Refer to Coding Clinic, Third Quarter 2007, pages 13-14, for additional information on coding chronic conditions.
Coding advice or code assignments contained in this issue effective with discharges September 23, 2011.
Paul Evans, RHIA, CCS, CCS-P, CCDS