ICD-10: Coding Snapshot
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7, with comorbidities of hypertension, chronic atrial fibrillation, and hyperlipidemia. He is currently smoking two packs of cigarettes a day and he is planning to quit at least six to eight days before surgery, for multiple reasons including decreasing the DVT, PE rates, and marginal ulcer problems after surgery, which will be discussed later on.
PHYSICAL EXAMINATION: On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us. His pulse is 78, temperature is 97.5, blood pressure is 132/94. Lungs are clear. He is a pleasant gentleman with stigmata of morbid obesity expected of his size. Abdomen is soft, nontender. No incisions. No umbilical hernia, no groin hernia, has a large abdominal pannus. No hepatosplenomegaly. Lower extremities; no pedal edema. No calf tenderness. Deep tendon reflexes are normal. Lungs are clear. S1, S2 is heard. Regular rate and rhythm.
ASSESSMENT: Morbid obesity due to excessive calorie intake with a BMI of 69.7. Nicotine dependence – Discussed cessation of smoking with patient. Hypertension – blood pressure elevated on today’s visit. Patient will be sent to cardiology prior to surgery. Discussed salt intake, exercise, etc with patient. Mixed hyperlipidemia – Patient to continue on medications and discussed diet as it relates to condition. Chronic atrial fibrillation – Patient to see cardiology prior to surgery. Will continue on medications unless cardiologist indicates otherwise. To get ECG and Holter next week.
I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term follow up, need to adhere to dietary and exercise guidelines. I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed.
All these are going to be at high risk for this patient secondary to his morbid obese condition. I also explained to him specific gastric bypass-related complications and long-term complications. The patient is at higher risk than the usual set of patients secondary to his morbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities. Smoking, of course, does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk. He will see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. He wants to go to surgery. All questions were answered. I will see him in few weeks before the planned date of surgery.
ICD-10-CM Code(s): E66.01 Morbid (severe) obesity due to excess calories
Z68.44 Body mass index (BMI) 60.0-69.9, adult
I10 Essential (primary) hypertension
I48.2 Chronic atrial fibrillation
E78.2 Mixed hyperlipidemia
F17.210 Nicotine dependence, cigarettes, uncomplicated
Rationale: In ICD-10-CM, codes for obesity are orgainized by severity and causation. In this case, the patient is documented as being morbidly obese with a BMI of 69.7. There is an instructional note under category E66 that states to use an additional code to identify the BMI, if known. The patient is 55 years old; therefore, the adult codes are referenced. The patient also has addressed comorbidities of hypertension, atrial fibrillation, and mixed hyperlipidemia. The patient is stated to be nicotine dependent, which should also be reported.