Posted June 7, 2023
By: Angie Kerr, HCS-D, HCS-O | Education Manager at Corridor
For coding purposes, a patient is only officially overweight or obese when their physician has documented a clinical diagnosis.
Obesity is a global epidemic. It affects millions of people worldwide and poses significant health risks that range from diabetes and heart disease to certain types of cancer, which are among the most common causes of morbidity and mortality. In the U.S., more than 40% of the population meets the clinical definition of obesity, and that is expected to increase to 50% of the population by 2030 at the current rate of increase.
Yes, obesity is a serious medical condition. An excessive accumulation of body fat is a major risk factor for many common, chronic comorbidities that contribute to the highest medical cost categories.
Obesity is defined as a body mass index (BMI) of 30 kg/m2 or higher. However, BMI alone is not the only indicator of obesity. Other factors such as family history, medical history, lifestyle habits, and even ethnicity affect the determination of obesity. Asians and Asian American have a lower BMI obesity set point than other races and ethnicities. With all these variables, only a qualified healthcare provider can make the most appropriate diagnosis for a particular individual.
What If My Patient Appears to Qualify as Obese?
When a clinician conducts a SOC OASIS assessment in a patient’s home, he or she performs a height and weight test to determine their patient’s BMI. If they discover that the patient’s BMI does not correspond with their current documented obesity status, the clinician should contact the patient’s primary care physician for the patient’s clinical diagnosis. The physician should provide clear documentation that confirms the obesity diagnosis or resolution of the condition in order to avoid red flags from auditors.
For the purposes of assigning diagnosis codes, under the guidance from PDGM, all diagnoses not specifically stated as “resolved” should be included on the patient’s 485. In the case of obesity, the code assignment should be based on the documentation provided by the patient’s physician, whether or not it correlates to the patient’s BMI.
Per the Coding Clinic Q4 2018, while BMI is used as a screening tool for patients who are overweight or obese, there is no coding rule that defines the BMI values that correspond to obesity or morbid obesity, since the conditions are coded only when diagnosed and documented by the provider or another physician caring for the patient. In addition, and according to this guidance from the American Hospital Association Coding Clinic, if the patient has a high BMI but does not have a confirmed diagnosis of obesity, then obesity should not be coded.
OASIS Coding Tip for Documenting Obesity
The important takeaway is that when assigning a diagnosis of obesity for coding purposes, it is crucial to have documentation from a qualified healthcare provider confirming the diagnosis based on medical criteria such as the BMI or other measurements of body fat. By following these guidelines, home healthcare providers and coding professionals can ensure accurate and consistent reporting of medical diagnoses, which is essential for providing high-quality care to patients and submitting accurate claims to payers.
Remember: A patient should not be coded as “obese” unless the physician’s documentation supports the diagnosis.
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Resources
American Hospital Association Coding Clinic. Copyright 2023 American Hospital Association. Accessed May 13, 2023 at AHA Coding Clinic Advisor Homepage | AHA Coding Clinic.
ICD-10-CM Official Guidelines for Coding and Reporting FY2023The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). Updated April 1, 2023.
Obesity: Symptoms and Causes. Mayo Clinic. 2023. Accessed May 13, 2023 at Obesity – Symptoms and causes – Mayo Clinic
National Institutes of Diabetes and Digestive and Kidney Diseases. National Institutes of Health. Overweight and Obesity Statistics. Updated September 2021. Accessed May 13, 2023 at Overweight & Obesity Statistics – NIDDK (nih.gov).
