Q&A: Coding history of obesity

Q: A question came up recently regarding coding obesity when it is only documented or listed as “a history of obesity.” This seems like it should be a simple concept, but we have heard varying opinions. Some subscribe to the idea that “a history of" could be resolved, so we should query. But if the associated body mass index (BMI) supports the diagnosis, should we capture the obesity code?

Should we capture obesity/morbid obesity and the associated BMI if the diagnosis is listed in the body of a note? Example: "Patient presents with shortness of breath, has history of chronic obstructive pulmonary disease (COPD), seizures, and obesity..."

A: No, you would need to query to clarify. The Coding Clinic regarding chronic conditions and coding when documented as “history of” pertain to diagnoses that never go away. Obesity, however, can go away. If the BMI supports that it is still present, then “history of” should be clarified.

Being overweight may place a patient at increased risk for certain medical conditions. However, obesity may only be reported when it meets the definition of a reportable diagnosis per Section III, Reporting Additional Diagnoses, of the ICD-10-CM Official Guidelines for Coding and Reporting. Neither the code for obesity nor the BMI code is assigned when there is no documentation that the obesity diagnosis meets the definition of a reportable secondary diagnosis. Obesity and morbid obesity are always clinically significant and should be coded and reported when documented by the provider. The BMI code may be reported with these conditions as well when BMI is documented, though BMI codes should not be assigned during pregnancy.

Editor’s note: This article was adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.