Coding Clinic 4th Quarter 2018 BMI

How are you all interpreting the Coding Clinic regarding BMI?  We have differing opinions in our organization and are trying to come to a consensus.

Are you interpreting this to mean - you can code the diagnosis (obesity, morbid obesity) BUT cannot report the BMI code unless it meets the definition of a secondary diagnosis (clinical evaluation, therapeutic treatment, diagnostic procedures, extended LOS, or increased nursing care/monitoring)?

Thanks!

Comments

  • No. Obesity is always clinically significant and should be coded if diagnosed/documented. If it is documented/captured, the BMI should also be captured.

    When other conditions that would also allow capture of BMI (overweight, malnutrition, anorexia, etc) are documented, they must meet reportability prior to either the BMI or the underlying condition can be coded.

    Katy

  • This is what Coding Clinic said to us on 10/26

     

    This letter is in response to your request for clarification regarding obesity and BMI coding.

     

    The Central Office has received many question about assigning BMI codes, therefore, updated advice was published in Coding Clinic Fourth Quarter 2018, pages 77-83. The advice clarifies that in order to assign a code for BMI, an associated clinical condition must be documented by the provider (i.e., morbid obesity, overweight, or obesity). It is not appropriate to assign a code for the BMI without an associated diagnosis. The advice further clarifies that obesity and morbid obesity are always clinically significant and reportable conditions that should be reported when documented by the provider.

     

    I trust that this information will be of assistance to you.

     

    Agree with what Katy just posted.

  • If it ‘impacts’ care, a condition is reportable.  If you were caring for a male that required hernia repair, how would it impact your care plan if your patient had a BMI of 25 versus a BMI of 41? Hence, it is ‘always’ reportable! 
  • If the BMI is documented but the associated diagnosis (obesity, morbid obesity, etc.) is not documented and there is no evidence in the medical record that the obesity impacted the care of the patient, would it be appropriate to query for the associated diagnosis? 

  • yes, as morbid obesity is always clinically significant.


    Katy

  • edited November 2018

    If the BMI is documented but the associated diagnosis (obesity, morbid obesity, etc.) is not documented and there is no evidence in the medical record that the obesity impacted the care of the patient, would it be appropriate to query for the associated diagnosis? 


    Depends on the BMI and what the clinical circumstances were.  In your question above, you did not say what the BMI was, only that it was documented.  Generally I don't look for Obesity with BMI's less than 32 to 33ish and I don't look for morbid without BMI's above 34 to 35ish or with clear documentation the the significant weight is impacting one or more weight related health problems.  Other definitions of morbid 100lbs over ideal body weight and or a BMI >40.
  • The BMI was documented as 40.65, but there was no documentation of obesity, morbid obesity, etc. No mention of skin or ambulation issues. There were no nursing, dietitian, or PT/OT notes in the chart and no orders for bariatric equipment or a special diet. It was a 2-day stay for gastroenteritis.  Comorbidities include hypertension.  Would you query for obesity / morbid obesity in this case?
  • This is a difficult question- it looks as though the only indicator you have is the BMI and we need to remember a patient may present with a high BMI and not be morbidly obese. If they are highly muscular their BMI will be higher for example. Do you have evidence to support the presence of any comorbidities?
  • 50 year old with hypertension and is a smoker with COPD - otherwise healthy.
  • 50 year old with hypertension and is a smoker with COPD - otherwise healthy.

    So, NOT a world champion body builder. :)  (I had the same thought as Laurie and was going to ask if he was a professional body builder). 

    I would expect a BMI above 40 to be a cofounding factor in the severity of both hypertension and COPD. 
  • Just to play devils advocate here with Laurie... With no other information to indicate whether the patient is/is not obese, I would query. This is where the provider needs to make the determination. The only time I would NOT query would be if there was clear indication that the BMI does NOT represent obesity. Body builder being one, amputations, etc...


    Katy

  • sounds like this would make a good topic for provider education
  • Question: BMI is 45 and the progress note states "morbidly obese" under the objective findings area. "General: AAOx3, NAD, Morbidly obese". Do you consider this a diagnosis or just a description requiring a query?
  • Erica, are your referring your BMI concern in context of pregnancy?
    Marjie
    mlbuntze@texaschildrens.org
  • edited January 4
    mlbuntze said:
    Erica, are your referring your BMI concern in context of pregnancy?
    Marjie
    mlbuntze@texaschildrens.org


    Not OB.  I know you cannot code BMI with pregnancy any longer.  We were really confused on this part, but I feel like we got it straight now.  BMI is not a diagnosis.  The obesity, morbid obesity,etc. are diagnoses.  Those can be coded per coding clinic as they are ALWAYS significant condition.  What was getting me:

    "Question:

    If the provider documents overweight in the history and physical and/or discharge summary only, without additional documentation to support the clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance. Can we also assign the BMI code?

    Answer:

    No, neither the code for overweight nor the BMI code is assigned if there is no documentation that the diagnosis of overweight meets the definition of a reportable secondary diagnosis. While overweight may place a patient at increased risk for certain medical conditions, it does not automatically meet the definition of a reportable diagnosis.

    For inpatient reporting purposes, the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring:

    clinical evaluation; or

    therapeutic treatment; or

    diagnostic procedures; or

    extended length of hospital stay; or

    increased nursing care and/or monitoring.


    I was hung up on this one and wasn't putting it together that this is referring to OVERWEIGHT as a "diagnosis" not obesity/morbid obesity.  I am good now!  We are coding it as directed per Coding Clinic (always have been), but I am more comfortable now with it. 


    Thank you all your help.  I'm glad I have a strong Coding Educator to keep my RN brain on track with coding!

  • But does the provider have to document how this affects the co morbid conditions and care of the patient?   I have had many charts where BMI is >40 and provider documents morbid obesity without any additional documentation of how this was monitored, evaluated, treated.  RN notes state that patient was up ad lib, turns self, independent with ADL, PT/OT notes state minimal assistance, no notes indicating recommendation of weight loss, no nutrition notes etc.  Imaging does not indicate any issues d/t body habitus etc.  If there is no documentation can we ASSUME that this affects the patient that has HTN, DMT2 or OSA without documentation of such?  Clinically we all know that this affects MANY things including co morbid conditions of DM, HTN, OSA etc. but from a denial standpoint do we need to see the providers making these links?  Very complicated issue
  • coding clinic has specifically answered this question and determined that obesity and morbid obesity are always clinically significant. This was reiterated in CCQ42018p77.


    Katy

  • This is a difficult question- it looks as though the only indicator you have is the BMI and we need to remember a patient may present with a high BMI and not be morbidly obese. If they are highly muscular their BMI will be higher for example. Do you have evidence to support the presence of any comorbidities?
    Hi Laurie, 

    I agree with you here.  So I would like to pose the question to you: When "BMI" is the only clinical indicator you have (NO diagnosis of obesity, morbid obesity, overweight, etc.), how do you clinically validate and support your query to the provider, especially to denial proof your clarification?  If your query is based on a 3-part format (Clinical Indicators, Risk Factors, and Treatment), what is your "Treatment"?  
    Example: 1 day LOS for elective procedure or 1-2 day LOS for UTI.  The patient was completely mobile and independent, Regular diet, no RD, PT, OT consult. No assistance by staff, no mobility/ambulation issues, no sleep apnea, no respiratory issues, no major chronic conditions.  Only a BMI of 40-41.  Based on CC guidance that the "diagnosis" must meet reportable criteria for secondary diagnosis, what is your "MEAT" for the associated medical diagnosis, which will then allow you to capture the BMI severity/CC? 

    I think this is where a lot of people are getting confused or hung up...It's not over whether to report an already stated diagnosis of obesity, morbid obesity, etc., it's when there is no associated diagnosis but a BMI documented in the Vital Signs by the RN or other staff.  The issue becomes the decision to query for it...


    Thank you so much for your assistance and guidance on this matter. 

    Angelica N. 
  • Had the same situation as Angelica N. NOTHING in the record except one VS recording of ht/wt/BMI of 41. 15-hour IP stay for pt who presented with a broken molar with abscess. NO PMH (documented as "no past medical history" in the progress notes). No mention of weight, body habitus anywhere in the record (by nursing or MDs). No home medications, BP WNL. No COPD, OSA, DM, other co-morbidities. No orders for special diet, nutrition consult, special equipment. No O2 provided. Pt admitted as an IP and next day ferried over to the dentist office for tooth extraction. No IVF. Only meds were Tylenol and antibiotics (2 doses). Pt dc home after tooth extracted. Received request to query for morbid obesity (to increase the SOI from 1 to 2). I feel this request would be un-ethical. Anyone's thoughts on this? 
  • One argument is that, per AHA, the condition of Morbid Obesity has been deemed a condition that is ‘always’ significant and reportable, and this forum has already indicated ‘why’ morbid obesity impacts care rendered and risk factors.

    It is EASIER  to ask for clinical relevance in the event RD, RN staff or MD counsel the patient, but, at least per AHA, this is not required in order to be reported.   

    Paul Evans, RHIA, CCDS
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