Wiki Obesity question

[ajanz54]

Documentation stated Obesity with BMI 54.3. How would this be coded, E66.8 & Z68.43 or E66.01 & Z68.43?

 

[xXxPARAGONxXx]

If the provider does not state that the obesity is a result of or caused by excessive caloric intake (or something essentially similar), then you cannot code Morbid (severe) obesity due to excess calories (ICD-10-CM E66.01). The health record must support the diagnosis.

Consider this caution from Humana,

Industry-standard diagnosis coding guidelines require medical coders to apply a strict literal interpretation to the healthcare provider’s medical record documentation. Coders are not allowed to “connect the dots,” make assumptions or presume to know the healthcare provider’s intent. Coders cannot clinically interpret information within the record, such as diagnostic test results or physical exam findings, to assign a code for a diagnosis that is not documented in the record. Accurate diagnosis code assignment is dependent on the healthcare provider clearly describing each medical diagnosis to the highest level of specificity.

In your example, the cause of the obesity is unspecified. “Unspecified” is equivalent to “not otherwise specified” (NOS), and vice-versa.



When we review the tabular, under Obesity (E66.*), we see the following:



All that being said, my recommendation is for you to query the provider to determine the etiology of the obesity. If the query remains unanswered or indeterminate, then you can code Obesity, unspecified (ICD-10-CM E66.9).

E66.8 applies to obesity due to other causes (as seen below); it does not apply to obesity for which the cause is not specified.



Finally, these words from AAPC,

Never assume anything. Instead, if documentation is unclear or incomplete, query the provider for more information.