Don’t Use an O Code When Obesity Isn’t Documented as a Pregnancy Complication
Question: A patient who is six weeks pregnant presents with pelvic pain on their right side. Past medical history includes morbid obesity, and the physical exam documented the body mass index (BMI) as 50. The physician does not mention any pregnancy complication related to morbid obesity, but did list obesity as a diagnosis in the record. Should I assign ICD-10-CM code O99.211 in this scenario? Connecticut Subscriber Answer: No, you shouldn’t assign O99.211 (Obesity complicating pregnancy, first trimester). If the documentation does not specify that the patient’s history of obesity or that the patient’s current BMI are factors complicating the pregnancy, then you won’t use an O code. Instead, you’ll want to consider the following codes that correspond to the conditions documented in the patient’s record: Since the patient presented with the pelvic pain, you’ll use R10.21 to show this as the reason for the visit. The remaining codes, E66.9, Z68.43, and Z3A.01, are assigned because they correspond to the documented conditions in the record. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
