Denials for BMI Morbid Obesity
We have experienced denials recently from payors for secondary diagnosis of BMI >40 / Morbid Obesity on surgical patients. We have the documentation by the physician along with the associated diagnosis, however the payor is denying stating it does not meet the criteria to be coded as a secondary dx i.e. documentation to support increased care/monitoring treatment etc. We have appealed endlessly with coding clinic guidance for coding this diagnosis, however all have been denied and the monies recouped.
Would like to know if others are experiencing similar audits and how you are handling it. We are working to address this on the front end and educate providers to assist us to capture information to support it like we would any other diagnosis. My fear is that failure to capture this important statistical information on our patient population will impact our data in many ways aside from reimbursement.
Dee Banet
dee.banet@nortonhealthcare.org
Would like to know if others are experiencing similar audits and how you are handling it. We are working to address this on the front end and educate providers to assist us to capture information to support it like we would any other diagnosis. My fear is that failure to capture this important statistical information on our patient population will impact our data in many ways aside from reimbursement.
Dee Banet
dee.banet@nortonhealthcare.org
Comments
Best Regards,
Cari Merlina RN, BSN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
p.970.871.2425
f.970.875.2796
Cari.merlina@yvmc.org
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Clinical significance of obesity
Coding Clinic, Third Quarter 2011 Pages: 3-4 Effective with discharges: September 23, 2011
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.
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Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Best Regards,
Cari Merlina RN, BSN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
p.970.871.2425
f.970.875.2796
Cari.merlina@yvmc.org
Very obvious this is reportable - I continue to be concerned that folks appear to ignore or use 'selectively' advice issued in Coding Clinic, which is our 'bible', applies everyone, including insurance companies. I can tell you anecdotally that when I have called such 3rd parties and discussed basic concepts of coding and compliance, they were ill-informed.
Please contest...I'd take to ALJ.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
Extracted for emphasis: "Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA
ICD-10-CM Official Guidelines for Coding and Reporting
FY 2016 Narrative changes appear in bold text Items underlined have been moved within the guidelines since the FY 2014 version Italics are used to indicate revisions to heading changes
The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). These guidelines should be used as a companion document to the official version of the ICD-10-CM as published on the NCHS website. The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO).
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official. The guidelines are organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting. It is necessary to review all sections of the guidelines to fully understand all of the rules and instructions needed to code properly.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Hi Dee, I received that very same denial a few weeks ago, for the same reason. My appeals letter quoted our coding clinic (as reported in previous comments) and I also showed documentation that bariatric equipment had to be used. I got a second letter back upholding the denial of this code and a request for money back (was the only CC on the record). I have sent it for a second (external) appeal. Was wondering if anyone else had the same problems.
Angelique Daigle BSN,RN,CCDS
CDI LEAD (interim contract)
St. Joseph Mercy, Oaklnad,
Pontiac, MI
Thanks
Peggy
Rhetorical question: What is correct thing to do? the thing that provides accurate and complete data picture of the patient?
Don
We have gotten denials for obesity and morbid obesity in both our med/surg inpatient population and our OB population. I have been working with providers to encourage them to make dietitian referrals and especially with our surgeons that they make a statement about the increased risk. For example: "Morbid obesity Increased monitoring due to increased risk of infection in the post- C-section patient" or "Morbid obesity due to excess calories. Encourage diet and exercise." The doctors are understandably frustrated as they feel it is silly to have to make these kind of statements. Especially in light of all of the research articles and well risks that obesity and morbid obesity carry.
I think it is apparent to any 'reasonable' person that Morbid Obesity impacts medical-decision-making and factors into the Care Plan for all such patients. This appears to be an example of a 3rd party using unreasonable standards. I'd think your only option now is to speak to Legal Counsel and take this to an Administrative Law Judge as you have exhausted all other avenues.
P. Evans, RHIA, CCDS
I agree that a 'reasonable' person would definitely acknowledge this relatively straightforward concept. Unfortunately that is not who we deal with often times. Thank you for your response!
I am not sure what recourse we will pursue. I am in a small rural critical access hospital as a one person inpatient CDI department and have been doing CDI here for about 10 months. We didn't not have someone that did appeals consistently before me and I don't think we have ever gone beyond the initial appeal step. I find working on the appeals both invigorating and maddening at the same time.
J Kramer RN, BSN
J. Kramer: You are not alone in your frustration! We are not always dealing with a reasonable or logical process, unfortunately. There is no easy answer for this vexing problem.
Paul
We have yet to win either of these appeals. I think educating providers to include dietary and exercise counseling is the only hope other than legal actions.
I wonder if our Providers started documenting a few blurbs about patient being counseled on healthy food choices and/or exercise, etc.. would mitigate some of these denials because that might show the Provider is stating the clinical relevance of the dx? Just a thought...we haven't seen many denials for morbid obesity and would love to mitigate the risk. I know it can be coded per coding clinic and that's what we follow.
Just curious if anyone has added anything like this into their EMR's?
Thanks, Jeff
We are also struggling with these ridiculous denials and have not had any luck with the appeals process. Our HIM department is now proposing that we begin asking all of our docs to document how the MO impacted the patient's care and how is was M.E.T. This proposal has been met with much push back.
I appreciate all of the feedback from this thread,
Deanna RN, BSN
I personally can't see the MDs accepting this idea given how ridiculous it is for anyone to question the fact that Morbid Obesity is always impactful upon the care of all clinicians involved in care of the patient - the RN team, the PT and OT team, pharmacy, radiology tech, and the MD teams. Bear in mind a condition is reportable if it 'impacts care and/or medical-decision-making'. I think we are all disturbed to learn some providers deny the significance of this condition.
Such denials serve to increase the frustration and animosity between the facility (CDI Teams & Coding representing the sites) and the RN 'validators' that represent the 3rd party, who too often deny claims incorrectly via incorrect application of coding rules (HIPAA) and also too often, use incorrect or outdated citations of clinical criteria in the scope of their work.
I not saying this criticize the wonderful work performed by educated competent RNs on the facility site, nor that of the competent and educated RNs representing 3rd parties. But, it is stated by many CDI professionals that some of the RNs working for 3rd parties use clinical criteria that is not up to date, and many of them apply coding rules improperly.
Paul Evans, RHIA, CCDS
Perhaps the key is that we always have RD evaluation documented in the progress notes and usually physicians now list it in the problem list! Some physicians even mention BMI !
Maxwell Sleiman RHIT, CCS, AHIMA Trainer
I'm not sure all of ours have an RD assessment, but we do require it to be documented along with the SMI by the provider. Thanks for the tip.,
Deanna
Just an update on this. My plan of attack has been encouraging the providers to state how the diagnosis is impacting the stay. This seems to be going pretty good as evidenced by having had several audits come back "no change" recommended that include the morbid obesity diagnosis and BMI code.
Unfortunately, I have again been presented with an incredibly maddening denial. Overview: 30 year old with diagnosis of sepsis due to cellulitis, OSA, hyponatremia due to hypovolemia and morbid obesity due to excess calories on the claim.
Pt. met sepsis criteria per our hospital policy with fever, tachycardia, leukocytosis, elevated lactic acid and elevated pro-calcitonin (not sepsis-3 as we have not adopted that as a facility)
Pt. had BMI-43 with provider documentation of morbid obesity due to excess calories with recommendation for diet and exercise and that it will likely complicate the lower extremity infection in every note and the discharge summary
Pt. had Na of 133 on admit. Stated as due to hypovolemia and expected improvement with IV fluids. Pt. Na level increased to 138 with fluids and remained normal at discharge.
Payor is denying the sepsis (they go by sepsis 3 so I was not overly surprised but I still plan to appeal based off our policy), the morbid obesity and BMI code as it "can only be coded if they extend length of stay or additional resources in terms of evaluation, treatment, and nursing care to manage the condition" and the hyponatremia code because "in current practice, hyponatremia with a sodium level . or = 130 mEqL is clinically insignificant and does not typically require treatment".
How can they deny a diagnosis that is present, the provider states consistently and outlines treatment, evaluation and monitoring related to that diagnosis?
We are a small rural hospital, I handle all the appeals for inpatient stays and we have never, that I am aware of, gone beyond the second appeal level for denials. I plan to appeal these based off coding guidelines.
Here I thought at least we were getting to where the morbid obesity diagnosis was getting denial proof as long as the provider documented some additional information explaining why it was valid in that particular patient. So just be aware, you may still get denials for this even with additional provider documentation. I may start trying to talk the provider into ordering a nutritional consult. Perhaps that is going to be the one additional thing to include in these patients who are morbidly obese but don't require the specialized equipment so we can get this diagnosis allowed on the claim and the entire clinic picture accurately defined.
Any other input or advice is appreciated, I just don't know that there would be buy in for going beyond in house second level appeals due to cost and our low volume.
Sorry to sound like I am venting....I kind of am....
Jacie Kramer RN, BSN
Maybe I am just not interpreting the rules and guidelines correctly?