Take back on a CC

I just received a letter from an insurance company who wants to take off a cc we submitted for Morbid obesity. The case was a CHF and Morbid obesity case DRG 292 but they want to change it to DRG 293 w/o cc. The patient had a documented BMI (42.20) and their letter states " the documentation on file does not show significant additional resources were used for or the length of stay was increased by BMI, therefore no additional payment will be made". Is there specific documentation we are required to support Morbid obesity other than the documentation of Morbid obesity and a BMI > 40.0? Is any one else seeing this in their denials? Any ideas or help appreciated. Thank you! 


  • Yes, we are seeing this same denial from one of the commercial insurances.  Be prepared, there WILL be more to follow.  We have attached the coding guideline regarding BMI when stated by the RD and their full assessments along with the recommendations.  Everyone doesn't get a visit by the RD with their own diet plan ordered just for them. :)   We have had some overturned and some not.  We are also seeing an increased number of denials with the documentation of both "obesity" and a different provider documenting "normal weight" or "over weight".  We have been sending an increased number of queries to confirm or rule out the conflicting documentation retrospectively. 
  • Refer to the coding clinic below:

    Clinical Significance of Obesity
    Coding Clinic, Third Quarter 2011 Page: 4
    Effective with Discharges: September 23, 2011
    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.
    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.

    also review your nursing documentation were there any interventions related to weight and concern related to increase risk of respiratory infection, DVT etc. 
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