Overweight and Obesity ICD-10-CM Coding
Overweight and obesity are abnormal or excessive fat accumulation that may impair health. These conditions put a patient at a higher risk for many health problems, including coronary artery disease, hypertension, type 2 diabetes mellitus, cholelithiasis, and breathing problems.
Body mass index (BMI) is an index of weight-to-height. It is calculated as a person’s weight in kilograms, divided by the square of the person’s height in meters (kg/m²). The World Health Organization (WHO) uses the following measures:
BMI greater than or equal to 25 is overweight
BMI greater than or equal to 30 is obese
The relevant ICD-10-CM codes are located in category E66, and are organized severity, contributing factors, and manifestation:
E66.01 Morbid (severe) obesity due to excess calories
E66.09 Other obesity due to excess calories
E66.1 Drug-induced obesity: There is an instructional note that states to use an additional code for adverse effect, if applicable, to identify the drug (T36–T50 with a fifth or sixth character 5)
E66.2 Morbid (severe) obesity with alveolar hypoventilation
E66.8 Other obesity
E66.9 Obesity, unspecified
Instructional notes at the beginning of the category state to code first obesity complicating pregnancy, childbirth, and the puerperium, if applicable (O99.21-); and, to use an additional code to identify the body mass index (BMI), if known (Z68.).
The body mass index codes are in category Z68. There are codes for adult BMI and codes for pediatric BMI. The adult codes are based on the numerical scale (e.g., 28.0–28.9), and the pediatric scale is based on the percentile for age range (e.g., 5th percentile to less than 85th percentile). BMI adult codes are for use for persons 21 years of age or older and the pediatric codes are for use for persons 2-20 years of age.
Subjective: A 49-year-old woman presented for weight loss treatment. She has attempted to lose weight through a variety of diets but has had no meaningful success. She states that she “loves food” and particularly is “addicted to sweets.”
Objective: On exam, she was 64 inches tall and weighed 230 pounds, yielding a body mass index (BMI) of 39.5.
Assessment: Severe obesity due to excessive caloric intake
Proper coding is E66.01 and Z68.39 Body mass index (BMI) 39.0-39.39, adult.