From the Forum: Manage denials for BMI morbid obesity

by Katherine Rushlau

When Dee Banet, RN, MSN, CCDS, CDIP, and her CDI team sent out a claim for a surgical patient with body mass index (BMI) greater than 40 with morbid obesity as a secondary diagnosis, they did not expect the claim to be denied; after all they had provider documentation along with the associated diagnosis. However, the payer denied the claim, stating it did not meet the criteria to be coded as a secondary diagnosis—including proper documentation to support increased care and monitoring treatment.

“We have appealed endlessly with Coding Clinic for guidance for this diagnosis,” says Banet, who is the CDI director at Norton Healthcare in Louisville, Kentucky. “All [of our claims] have been denied [again] and the monies recouped.”

In a recent discussion on the ACDIS Forum, Banet asked ACDIS colleagues if they experienced similar audits, and sought advice on how to handle them. “We want to address this on the front end and educate providers to capture information like we would any other diagnosis,” said Banet. “My fear is that failure to capture this important statistical information on our patient population will affect our data in many ways aside from reimbursement.”

A number of Forum users were surprised. One user says they are never questioned about this diagnosis. Another suggested sending the payer clinically supported documentation (i.e., an article from a medical journal) on morbid obesity and numerous associated health effects. Another user cited Coding Clinic, Third Quarter 2011, p. 3–4, which states:

Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider.

In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity  is documented. The diagnosis of obesity is one of the more difficult  documentation matters that CDI specialists likely face, said Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, an E/M and procedure- based coding, compliance, data charge entry, and HIPAA privacy specialist, in a recent article published in JustCoding. According to the National Institutes of Health (NIH), morbid obesity is defined as:

• Being 100 pounds or more above your ideal body weight
• Having a body mass index (BMI) of 40 or greater
• Having a BMI of 35 or greater and one or more comorbid conditions

The NIH breaks down obesity intoclasses: 

• Class I is BMI 30–34.9 kg/m2
• Class II is BMI 35–39.9 kg/m2
• Class III is BMI greater than 40 kg/m2

By using the information documented in the record, coders can report the BMI from a dietitian’s note or from the physician’s documentation, says Webb. However, if the numeric BMI falls into the “class” status, the facility can report and code this as a Class I, II, or III obesity state. The obesity documentation still has to be clearly defined within the medical record. With that, there should be a correlation from the physician to support the obesity code assignment and how it is currently impacting the patient’s current care and ongoing plan, according to Webb. Additionally, the Uniform Hospital Discharge Data Set (UHDDS) definition of “other diagnoses,” or secondary  diagnoses, describes those conditions that coexist at the time of admission, or develop subsequently, and that affect the patient care for the current care episode.

To be considered a secondary diagnosis the condition must require any of the following:

• Clinical evaluation
• Therapeutic treatment
• Diagnostic studies
• An extended length of stay
• Increased nursing care and/or monitoring

The many ramifications of increased nursing care—the propensity to develop an ulcer of the skin, difficulty for the nurse or physician in performing a full exam, modification of dosing by the provider, and difficulty obtaining clear views of internal sites while undergoing various radiological studies—represent just a few reasons obesity is always reportable, says Paul Evans, RHIA, CCS, CCS-P, CCDS, regional clinical documentation manager for Sutter
West Bay in San Francisco. When dealing with denials that cite Coding Clinic, Evans suggests CDI teams know the rules well themselves and make sure the payer complies with the Official Guidelines for Coding and  Reporting, which states: adherence to these guidelineswhen assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act. Rules governing code assignment follow a strict structure: first the rules in the Tabular List of the code set, then the Official Guidelines for Coding and Reporting, then the AHA’s Coding Clinic for ICD-10-CM/ PCS (previously Coding Clinic for ICD-9-CM).

“It is very obvious that [morbid obesity] is reportable,” Evans responded on the ACDIS Forum. “I continue to be concerned that folks appear to ignore or ‘selectively’ use advice issued in Coding Clinic, which is our ‘Bible’ and applies to everyone, including insurance companies. I can tell you anecdotally that when I have called such third parties and discussed basic concepts of coding and compliance, they were ill-informed.”

When faced with a denial for obesity, CDI teams need to not only ensure that the documentation is complete and accurate, but also back up their appeal with items like scholarly articles and official guidance that show why the condition influences patient care—which, according to Coding Clinic, is always the case. “Obesity is always reportable,” says Evans. “Period.”

Editor’s note: Get involved in the CDI conversation and post your questions, conundrums, tips, and training tricks in the new ACDIS Forum at forum.acdis.org. Katherine Rushlau is the ACDIS editor. Contact her at  krushlau@acdis.org.