Take back on a CC

tenglish1tenglish1
in CDI Management
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! 

Comments

  • afloyd24afloyd24
    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. 
  • lprescott1lprescott1
    Refer to the coding clinic below:

    Clinical Significance of Obesity
     
    Coding Clinic, Third Quarter 2011 Page: 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.

    also review your nursing documentation were there any interventions related to weight and concern related to increase risk of respiratory infection, DVT etc. 
  • cynthia.mead@nahealth.comcynthia.mead@nahealth.com

    We're seeing the same thing and appeal the denials. We have won a few by quoting the CC posted by Laurie.

    One of the things I'm wondering about  is if it would be helpful to add fields to the EMR for nursing to document the additional care needed by morbidly obese patients?

    Not sure of what to add but maybe something like:

    Hoyer lift needed to reposition pt

    X# staff needed to reposition patient

    Additional skin care needs/Assessments performed d/t obesity


    Any thoughts anyone?

    Cynthia



  • afloyd24afloyd24

    We are seeing the same type denials.  Our nursing staff and PT staff do a good job of documenting extra care for obese patients.   If PT is involved, they will document "additional PT tech present to assist with lifting, spotting of patient d/t obesity" or something similar.  Our nursing staff will also document that additional staff members were used to turn, lift, etc.  This is good just to "cover" them in case of an incident and the account goes to court.  Safety first!  And I bet staff nationwide are doing the same, they may need additional education or reminders to document this way.   

  • lprescott1lprescott1
    I refer to this as the "invisible care" many dont think it is important to document but we know it is. i would suggest education to nursing about it. also remember those old fashioned nursing care plans? My bet they may include interventions related to the patient's size and morbid obesity. this can be used as support as well. 
  • cynthia.mead@nahealth.comcynthia.mead@nahealth.com

    I like the care plan idea! It would be easy to create and implement and could include the need to use additional staff to safely reposition the patient.

    Any one have an example?

    Cynthia

  • cselukecseluke
    Anthem has a policy on BMI > 40 and associated diagnoses. Briefly, the policy states they will not pay the DRG with this cc unless there is evidence in the record of longer LOS, increased use of resource, etc. I have appealed one of these denials using the cited Coding Clinic but it was a waste of time. The commercial insurers are free to make their own rules. 
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