Obesity/mrbid besity/bdy mass index (adult) Obesity/Mrbid Obesity/BMI Definitins and backgrund Diagnsis cde assignment is based n the prvider s clinical judgment and crrespnding medical recrd dcumentatin f the specific besity cnditin. There are varying resurces prviders use t define and diagnse besity, fr example: Accrding t the Centers fr Disease Cntrl and Preventin, verweight and besity are labels fr ranges f weight that are greater than what is generally cnsidered healthy fr a given height. The terms als identify ranges f weight that have been shwn t increase the likelihd f certain diseases and ther health prblems. MedlinePlus (a service f the U.S. Natinal Library f Medicine and the Natinal Institutes f Health, r NIH) advises, Obesity means having t much bdy fat. It is different frm being verweight, which means weighing t much. The weight may cme frm muscle, bne, fat and/r bdy water. Bth terms mean that a persn s weight is greater than what s cnsidered healthy fr his r her height. Likewise, the American Heart Assciatin (AHA) advises that if a persn has a bdy mass index (BMI) f 40 r higher, the persn is cnsidered extremely bese (r mrbidly bese). The NIH defines mrbid besity as fllws: Being 100 punds r mre abve ideal bdy weight; r Having a BMI f 40 r greater; r Having a BMI f 35 r greater and ne r mre cmrbid cnditins Obesity classificatin established by the Wrld Health Organizatin (WHO) in 1997 is based principally n the assciatin between BMI and mrtality. WHO states that the cut-ff pints fr degrees f verweight shuld nt be interpreted in islatin but always in cmbinatin with ther determinants f mrbidity and mrtality (disease, smking, bld pressure, serum lipids, glucse intlerance, type f fat distributin, etc.). The Natinal Heart, Lung and Bld Institute (NHLBI) recmmends that an assessment f an bese patient shuld include the evaluatin f BMI, waist circumference and verall medical risk. NHLBI uses the terms clinically severe besity and extreme besity in place f the cmmnly used term mrbid besity. Bdy Mass Index (BMI) Obesity Class Underweight <18.5 Nrmal 18.5 24.9 Overweight 25.0 29.9 Obesity 30.0 34.9 I 35.0 39.9 II Extreme besity 40 III The preferred besity metric in research is the bdy fat percentage (BF%) the rati f the ttal weight f a persn s fat t his r her bdy weight. Accurate measurement f bdy fat percentage is much mre difficult than measurement f BMI; therefre, BMI is used as a way t apprximate BF% and can be easily calculated frm a persn s height and weight. Althugh BMI crrelates with the amunt f bdy fat, BMI des nt directly measure 2516ALL0616-D Page 1 f 5
Obesity/mrbid besity/bdy mass index (adult), cntinued bdy fat. As a result, sme peple (fr example, athletes) may have a BMI that identifies them as verweight even thugh they d nt have excess bdy fat. Nte: The Centers fr Medicare & Medicaid Services (CMS) has develped criteria fr bariatric surgery cverage, but these are nt guidelines fr diagnsis r cding. In summary: In additin t BMI, physicians diagnse mrbid besity based n multiple cnsideratins including, but nt limited t, waist measurement, calculatin f bdy fat, muscular structure and medical risks assciated with cmrbidities. Causes and risk factrs fr develpment f besity Physical inactivity Unhealthy diet Unhealthy eating habits Lack f adequate sleep Certain medicatins Signs and symptms Clthes feeling tight and need fr larger-size clthing Increased weight Diagnstic tls Medical histry and physical exam Height and weight calculatin f BMI Measurement f bdy fat percentage Certain medical cnditins Genetics and family histry Older age Scial and ecnmic issues Cultural issues Increased BMI Increased waist circumference Measurement f waist circumference Evaluatin f cmrbid cnditins Cmplicatins and health risks Shrt-term Shrtness f breath with activity Snring Difficulty sleeping Fatigue Back and jint pain Lng-term High bld pressure (hypertensin) High chlesterl and triglycerides Type 2 diabetes mellitus Metablic syndrme Heart disease Strke Kidney disease Sleep apnea Cancer Fatty liver disease Gallbladder disease Ostearthritis Preventin and self-management Nutritinally balanced diet Healthy eating habits, including prtin cntrl Regular physical exercise Gd sleep habits Medical treatment Medicatins Weight-lss surgery Tracking and trending weight, BMI and waist circumference Behavir mdificatin Supprt grups Realistic gal setting Page 2 f 5
Obesity/mrbid besity/bdy mass index (adult), cntinued Dcumentatin tips fr health care prviders In the subjective sectin f the ffice nte, dcument the presence r absence f any current symptms related t besity, mrbid besity, verweight, etc. In the bjective sectin f the ffice nte, dcument the patient s height, weight and BMI. (The medical cder is nt allwed t use the patient s dcumented height and weight t calculate the BMI and assign a crrespnding cde. Rather, the medical recrd must specifically dcument the BMI.) The physical exam shuld include any current assciated physical exam findings (such as bese, mrbidly bese, verweight, etc.). In the final assessment, dcument the verweight r besity diagnsis t the highest level f specificity, as in mrbid besity, severe besity, extreme besity, verweight, etc. Include any assciated diagnses that caused the verweight r besity diagnsis; use terms that clearly shw the cause-and-effect relatinship (such as due t, secndary t, related t, etc.). Als dcument any cexisting diagnses that are impacted by the verweight r besity diagnsis. D nt describe a current besity diagnsis as histry f. In the plan sectin, dcument the specific treatment plan fr the besity diagnsis (e.g., referral t nutritinist; patient educatin related t the besity cnditin with infrmatin regarding balanced diet; plan fr return fllw-up; etc.). tips and resurces fr cders Overweight and besity classify t subcategry E66. Furth and fifth characters are required t specify the particular type f verweight r besity. E66.Ø Obesity due t excess calries E66.Ø1 Mrbid (severe) besity due t excess calries E66.Ø9 Other besity due t excess calries E66.1 Drug-induced besity E66.2 Mrbid (severe) besity with alvelar hypventilatin E66.3 Overweight E66.8 Other besity E66.9 Obesity, unspecified Categry E66 includes an instructinal nte that advises t use an additinal cde t identify BMI if knwn (Z68.-). BMI classifies t categry Z68. BMI adult cdes are used fr persns 21 years f age r lder. Fr the adult BMI cdes, furth and fifth characters are assigned t specify the BMI range. BMI cdes shuld be reprted nly as secndary diagnses. As with all ther secndary diagnsis cdes, the BMI cdes shuld be assigned nly when they meet the definitin f a reprtable additinal diagnsis (see the ICD-10- CM Official Guidelines fr Cding and Reprting, Sectin III, Reprting Additinal Diagnses). Fr BMI, cde assignment may be based n medical recrd dcumentatin frm clinicians wh are nt the patient s prvider (i.e., physician r ther qualified health care practitiner legally accuntable fr establishing the patient s diagnsis), since this infrmatin is typically dcumented by ther clinicians invlved in the care f the patient (e.g., a dietitian ften dcuments BMI). Hwever, the assciated diagnsis (such as verweight r besity) must be dcumented by the patient s prvider. If there is cnflicting medical recrd dcumentatin, either frm the same clinician r different clinicians, the patient s attending prvider shuld be queried fr clarificatin. (ICD- 10-CM Official Guidelines fr Cding and Reprting) Page 3 f 5
Obesity/mrbid besity/bdy mass index (adult), cntinued Cding examples Example 1 Scenari Medical recrd dcuments a current diagnsis f severe besity. Recrd states the patient s height is 5'4" and weight is 244 lbs. There is n dcumentatin f BMI. Example 2 Scenari Vital signs sectin f recrd dcuments weight 489 punds, height 65 inches and BMI 81.37. Final Impressin dcuments simply Obesity. Cding Cde E66.Ø1 can be assigned based n dcumentatin f a current diagnsis f severe besity. N cde can be assigned fr BMI, as the medical cder is nt allwed t calculate the BMI and assign a crrespnding cde. Rather, the BMI must be calculated and dcumented in the medical recrd by the prvider. Cding With n ptin t query the prvider, cde E66.9 must be assigned fr the final diagnsis dcumented as simply besity. The cder is nt allwed t apply a clinical interpretatin t the recrded weight and BMI r t change the prvider s final impressin t Mrbid Obesity. Cde Z68.45 fr BMI f 81.37 wuld be assigned as a secndary diagnsis. Example 3 Scenari Medical recrd dcuments a BMI f 38, but final assessment includes a diagnsis f mrbid besity. Cding Assign cde E66.Ø1 fr mrbid besity. BMI is nly ne diagnstic indicatr f mrbid besity. Prviders may use ther criteria t arrive at a final diagnsis f mrbid besity. Example 4 Scenari Patient presents t the ffice with cmplaints f severe right ear pain. Vital signs sectin f the recrd dcuments weight 275 punds, height 62 inches and BMI f 50.3. After physical exam, the prvider dcuments a final impressin f right titis externa. Cding Assign cde H6Ø.91, Unspecified titis externa, right ear. The BMI shuld nt be cded, since there is n dcumentatin that shws the BMI has clinical significance fr titis externa. Example 5 Scenari Final Assessment dcuments Extreme besity with bdy mass index f 68.4. Cding Assign cdes E66.Ø1 and Z68.44. Extreme besity is equivalent t severe r mrbid besity. Example 6 Scenari Recrd dcuments 3-mnth fllw-up fr diabetes mellitus and hypertensin. Vital signs sectin f the recrd dcuments BP 126/70, weight 230 punds, height 62 inches and bdy mass index f 42.06. After bld pressure check, physical exam and lab assessment, the prvider dcuments the final impressins f Cding Assign cdes E11.9, I1Ø, Z68.41. Bdy mass index is cded since the BMI has clinical significance fr diabetes and hypertensin. Page 4 f 5
Obesity/mrbid besity/bdy mass index (adult), cntinued diabetes type 2 cntrlled with n cmplicatins, benign essential hypertensin with gd cntrl and BMI f 42. Example 7 Scenari Recrd states the patient presents t the ffice fr physical exam. Patient reprts she is ding well, needs medicatin refills and has n ther cmplaints. Vital signs sectin f recrd dcuments height 54.5 inches, weight 260.8 punds and BMI 61.96. Final impressin dcuments Well Adult Exam. The recmmendatins sectin states the patient was advised t lse weight. The patient instructins sectin dcuments: 1) Discussed imprtance f regular exercise and recmmended starting r cntinuing a regular exercise prgram fr gd health; and 2) The patient was encuraged t lse weight fr better health. Cding Assign cde ZØØ.ØØ, Encunter fr general adult medical examinatin withut abnrmal findings. The BMI shuld nt be cded, since there is n assciated principal diagnsis that shws its clinical significance. Even thugh the recmmendatins sectin shws the patient was encuraged t lse weight and exercise, the prvider des nt link this treatment plan t a current primary diagnsis with which the secndary BMI cde can be assigned. Prvider did nt dcument a specific current diagnsis. References: American Hspital Assciatin Cding Clinic; American Heart Assciatin; Centers fr Disease Cntrl and Preventin; Official Guidelines fr Cding and Reprting; May Clinic; MedlinePlus; Natinal Heart, Lung and Bld Institute; Natinal Institute f Diabetes and Digestive and Kidney Diseases; Cleveland Clinic Page 5 f 5