1st Morbid Obesity Denial
I am looking for help with a denial for the only CC on a 3 day LOS for the following per our level one appeal. Essentia Health writes successful appeals with this payer however this is a first around BMI and Morbid obesity. We are now deciding to either withdraw further appeals (however we feel this is an impacting and warranted dx) or write a 2nd appeal. Looking for what work(s) for your organizations with regards to >40 BMI-->morbid obesity and supporting clinical data.
This letter is in response to your audit findings that a coding and DRG change is required for the above-referenced patient’s inpatient admission, based on your suggested removal of our submitted secondary diagnoses, morbid obesity (E66.01) and BMI 40-44.9 (Z68.42) as having insufficient clinical evidence, having no impact on patient care, and lack of supportive documentation to substantiate these conditions. We find this proposal unwarranted, based on documentation in the medical record, and that these diagnoses meet the definition of a valid and substantiated secondary diagnosis that affected this patient’s care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospitalization, or increased nursing care and/or monitoring. We disagree with removing these diagnoses, and the resulting change in DRG from DRG 481 to DRG 482.
This **** patient with multiple co-morbid conditions (including conditions that are frequently noted to be weight-related, such as DM type 2, OSA, HTN, OA, GERD), presented with right hip pain and drainage for surgical treatment with irrigation and debridement of prosthetic hip joint. Contrary to your Reviewer’s comments in your review determination letter, this condition did affect the patient’s care during this admission, specifically, it increased nursing care. I have attached nursing flowsheets which documented the need for assistance of 2 for ambulation or transfers and FWW, substantiating the need for increased nursing care during this admission. Morbid obesity is well known in the literature and in clinical practice to increase the medical complexity of care and create heightened risk of medical/surgical complications.
Coding Clinic, Fourth Quarter 2018, page 77 noted, “Obesity and morbid obesity are always clinically significant and reportable when documented by the provider. In addition, if documented, the body mass index (BMI) code may be coded in addition to the obesity or morbid obesity code” and “…the provider must provide documentation of a clinical condition, such as overweight, obesity or morbid obesity, to justify reporting a code for the body mass index. As stated in the Official Guidelines for Coding and Reporting, Section I.B.14, the associated diagnosis (such as overweight or obesity) must be documented by the patient's provider. If the linkage between the BMI and a clinical condition is not clearly documented, query the provider for clarification. ICD-10-CM does not provide definitions, or a list of diagnosis codes associated with BMI. Coding Clinic, Fourth Quarter 2018, p82 noted, “…it would be appropriate to assign the BMI as a secondary code with associated diagnoses such as malnutrition, anorexia nervosa or other eating disorders, cachexia, and abnormal weight loss/gain.” These official coding references further support the validity and substantiate our claim submission that included these diagnoses for this patient’s care. As stated earlier, morbid obesity is well known in the literature and in clinical practice to increase the medical complexity of care and create heightened risk of medical/surgical complications.
Given the fact that this patient’s documentation and clinical picture were consistent with increased nursing care related to the patient’s elevated BMI at 42.32 (Z68.41) and morbid obesity (E66.01), we stand by our original submission, DRG 481 with Z68.41 and E66.01 as valid secondary diagnoses for this admission. We hope after careful re-review of the documentation attached and associated Coding Clinic guidelines, you will agree and uphold our original claim submission.
Thank you in advance for your time and help.
Tracy Boldt
Essentia Health System
Comments
"They also brought up obesity and how there are conflicting instructions on whether it is a codeable diagnosis. I think the issue here arises when CDISs try to apply what Allen called the traditional “five rules: that is, clinical evaluation, therapeutic treatment, diagnostic procedures, extending length of stay, and increasing nursing care or monitoring. The Uniform Hospital Discharge Data Set (UHDDS) did not mandate these five conditions; that was commentary based on the coding bible. What the UHDDS does say is “conditions that coexist at the time of admission,” which applies to obesity.
Obesity is always clinically significant – it causes disease, it impacts and affects treatment and dosing, it may change the surgical approach or affect healing. We may need more nursing lifting help, or oversized beds or wheelchairs. But does the provider have to explicitly document these as active treatments to be able to code obesity? I don’t think so. I do think that any patient who comes to the hospital with significant obesity should get dietary counseling, similar to tobacco cessation counseling. That is just in our patients’ best interest. It may not be pertinent to the current admission, but it is important to the patient’s longitudinal care and long-term well-being."
Hope this helps!
I have a letter written by our anesthesiologist chief that supports and defends the reporting of morbid obesity in surgical patients. I can send you a copy.