# Morbid Obesity - The physician says the patient



## maklock (Oct 30, 2014)

I have a question regarding the coding of Morbid Obesity.

The physician says the patient is obese in the examination portion of the note. The BMI is 45.3 which is listed in the physical examination portion of the note. The actual diagnosis of morbid obesity is only found in the past medical history portion of the note. 

Would you code 278.01 and V85.42?

Thanks,
Marilee A. Raker, CPC, CCA


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## Amy Pritchett (Oct 30, 2014)

Marilee,
If you look in the guidelines under ICD-9 code 278.0x you will see the BMI levels are listed for each code. The BMI level for 278.01 is 40 or greater. You stated in your post that the BMI is documented as 45.3, which would fit into this ICD-9 description. 

Also, the BMI would be listed as V85.42.

I hope this helps you


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## maklock (Oct 30, 2014)

My thinking was yes because the provider does diagnose obesity so I was questioning if I could use the history for a more difinitive diagnosis since I have the BMI to support it.

Thanks,
Marilee A. Raker CPC, CCA


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## Amy Pritchett (Oct 30, 2014)

I would not use the history since the patient is still at the BMI of 45.3 at this time. It would be redundant in my opinion.


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## maklock (Oct 30, 2014)

I did not mean the history code, I meant to pull the diagnosis from the history section of the note. 

Coding guidelines are grey at times when it comes to history and diseases. Especially because we see the provider use the term history differently than we interperet it in the coding world.


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## kumeena (Oct 30, 2014)

I do have a same problem with my Physicians. As per coding guidelines diagnosis should be written by provider. If provider does not write "morbid" how can we go with BMI? Is it Ok to change physician diagnosis?

Thank you


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## mitchellde (Oct 30, 2014)

The coding guidelines state that the provider must state the obesity and the obesity type, ie morbid, in the office note.  If the BMI and documentation of the obesity type does not match then the needs to be returned to the provider for clarity of the obesity or the one that documented the BMI must redo the BMI to the most current calculation.  So what you have is one of two things.  The patient lost weight and the BMI is not current, or the provider simple failed to document accurately the level of obesity.  The coder is not the one to unravel this, your job was to discover the discrepancy which you have done, not the provider must determine the correct documentation, otherwise it cannot be coded.


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## maklock (Oct 30, 2014)

The diagnosis of Morbid obesity is in the PMH only. This is within the note.

The diagnosis has been made already at some point, the current provider is saying obese. ???


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## mitchellde (Oct 30, 2014)

PMH is just that it is history.  The exam note is present. You cannot use history for the current dx.  The provider states obesity but the BMI is inconsistent.  The provider needs to amend the document by either changing the level of obesity or the BMI.  There is no way for the coder to know or make the determination as to which is the one that is correct.  There are three levels of obesity; overweight, obese, morbidly obese.  The coding guidelines are clear that the provider must document the level of obesity and that and the documented BMI must match.


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## mitchellde (Oct 30, 2014)

I understand that some disagree with the coder being able to code morbid obesity when supported by the BMI..  Here is the quote from the guidelines:

For the Body Mass Index (BMI) and pressure ulcer stage codes, code assignment may be based on medical record documentation from clinicians who are not the patient?s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient?s diagnosis), since
this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often documents the pressure ulcer stages). *However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient?s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient?s attending provider shouldbe queried for clarification.*
Just because the PMH states morbid obesity and the BMI supports that, the actual present exam by the provider staes obesity which does not support the BMI.  The coder cannot take the easy route here and just assume the provider mean morbid obewsity.  Again what if the patient has been working hard to lose weight and the BMI was not updated.  All you know from reading the note is that there is a discrepancy.


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## llanesv2018 (Sep 2, 2015)

*morbid obesity*

a physician documented MORBID OBESITY AND BMI 34 but he documented comorbidity disease (OSA, CHRONIC BRONCHITIS, CHO^; SOB, HTN, chronic pain ) I went to doctor and he said that the patient has MORBID OBESITY because, her  serious health condition,  and she is not able to breathing or walking.. I should select 278.01 based in the physician proper documentation or I should not assign the code because BMI34? PLEASE HELP ME!!


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## llanesv2018 (Sep 2, 2015)

*morbid obesity*

IF PHYSICIAN DOCUMENT MORBID OBESITY WITH BMI-34 ; SHOULD I SELECT 278.01 (CO-MORBIDITY HTN, CHRONIC PAIN; OSA; CHRONIC BRONCHITIS; DIFFICULTY TO WALK, DEPRESSED)serious health condition that are interfering with basic physical functions such as breathing or walking. What is the correct code to be assigned?


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## mitchellde (Sep 2, 2015)

The level of obesity does not match the level of the BMI.  the provider needs to change one or the other.  This is not something the coder can do.  If the nurse documented the BMI the the nurse can recalculate and change it.  Otherwise you can code the morbid obesity only but it will probably be rejected without the BMI.


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## lgardner (Sep 3, 2015)

vllanes said:


> IF PHYSICIAN DOCUMENT MORBID OBESITY WITH BMI-34 ; SHOULD I SELECT 278.01 (CO-MORBIDITY HTN, CHRONIC PAIN; OSA; CHRONIC BRONCHITIS; DIFFICULTY TO WALK, DEPRESSED)serious health condition that are interfering with basic physical functions such as breathing or walking. What is the correct code to be assigned?



I researched this a year or two ago and found that a BMI of 35 or greater CAN be diagnosed as morbid obesity by a provider if he/she feels that there are relevant obesity related conditions or comorbidities.

I can't find the definition on CMS (or in my drawers of information) at the moment, but I did find this:

"The surgical literature promotes a more granular definition and developed the criteria of BMI of 35 or greater with obesity related health conditions or comorbidities.  Most bariatric surgery associations and programs consider this to be morbid obesity.  In fact, CMS itself identifies (Transmittal 2641, Jan 29, 2013) that bariatric surgery for morbid obesity is a covered procedure and only requires a BMI ≥ 35 with comorbidity."

hope this helps.


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