Coding BMI without associated DX

rmooney1114

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Hello, I need some clarification, if you will on something. As it pertains to Risk Adjustment Coding, is the coder allowed to extract just the BMI code if documented, without any associated dx also being documented, such as obesity, morbid obesity, overweight? I understand that the BMI codes are secondary codes only so they cannot be primary dx codes, but as far as reporting for risk can the BMI code be reported alone if the provider did not document anything pertaining to the patient's weight?
 

hperry10

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Good question!

Hello, I need some clarification, if you will on something. As it pertains to Risk Adjustment Coding, is the coder allowed to extract just the BMI code if documented, without any associated dx also being documented, such as obesity, morbid obesity, overweight? I understand that the BMI codes are secondary codes only so they cannot be primary dx codes, but as far as reporting for risk can the BMI code be reported alone if the provider did not document anything pertaining to the patient's weight?
I would like to know this as well. We are being instructed by an auditor to add the BMI code and the obesity code or overweight code even thought the provider makes no mention of obesity, etc. The BMI is documented and that is it. I hope a risk adjustment coder will chime in here.

Heather CPC
 

mitchellde

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In the coding guidelines it states the coder may code the BMI as long as it is captured from any person in the office such as a nurse. the diagnosis of obesity or morbid obesity however must be rendered by the provider and cannot be assume by the coder. The difference is the BMI is a number that is calculated based on as set of numbers and a proven formula. really anyone can do it and in some cases the EMR is performing the calculation. However obesity is a diagnosis and it cannot be assume given a number that is calculated out of context.
 

hperry10

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In the coding guidelines it states the coder may code the BMI as long as it is captured from any person in the office such as a nurse. the diagnosis of obesity or morbid obesity however must be rendered by the provider and cannot be assume by the coder. The difference is the BMI is a number that is calculated based on as set of numbers and a proven formula. really anyone can do it and in some cases the EMR is performing the calculation. However obesity is a diagnosis and it cannot be assume given a number that is calculated out of context.
Thank you Debra. That is what we had thought but were unsure after hearing from the auditor.
 

rmooney1114

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I am a risk adjustment coder, and I don't think the question is being understood correctly. I have spoke with several other risk coders and everyone says it depends on the project and assignment. My question is not who can document. I know that anyone can basically document the BMI, but that the provider needs to specifically documented if the patient is obese or morbidly obese. The question is, can the BMI code be reported/captured without an associated obesity code. If the provider does not document that the patient is obese, can the Z-code for the BMI still be reported. Technically BMI codes are listed as secondary codes, meaning they cannot be primary, but there is no "Code first" rule indicating that obesity needs to be coded first in order to code the BMI. Several other people on different risk adjustment forums have stated that some organization allow for just reporting the BMI regardless of any associated obesity code and others state that in order to capture the BMI code there needs to be an associated obesity code. I just wanted to see what everyone else on here thought because it is such a grey area in risk coding.
Thank you
 
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sighle

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Coding BMI without diagnosis of obesity

I am a risk adjustment coder, and I don't think the question is being understood correctly. I have spoke with several other risk coders and everyone says it depends on the project and assignment. My question is not who can document. I know that anyone can basically document the BMI, but that the provider needs to specifically documented if the patient is obese or morbidly obese. The question is, can the BMI code be reported/captured without an associated obesity code. If the provider does not document that the patient is obese, can the Z-code for the BMI still be reported. Technically BMI codes are listed as secondary codes, meaning they cannot be primary, but there is no "Code first" rule indicating that obesity needs to be coded first in order to code the BMI. Several other people on different risk adjustment forums have stated that some organization allow for just reporting the BMI regardless of any associated obesity code and others state that in order to capture the BMI code there needs to be an associated obesity code. I just wanted to see what everyone else on here thought because it is such a grey area in risk coding.
Thank you
Yes, the BMI can be coded without an accompanying obesity code. The BMI should be coded if applicable in order to have the info on the claims data for HEDIS.

To further clarify, 1. the BMI can be calculated by other health care professionals and 2. the BMI code is a secondary code but there does not need to be an associated obesity code. (think about it- the calculated BMI may not even indicate overweight but the BMI should still be coded if calculated).

I hope that answers your question.

Sighle, RN, soon to be CRC- I hope!
 

amla12

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Yes, the BMI can be coded without an accompanying obesity code. The BMI should be coded if applicable in order to have the info on the claims data for HEDIS.

To further clarify, 1. the BMI can be calculated by other health care professionals and 2. the BMI code is a secondary code but there does not need to be an associated obesity code. (think about it- the calculated BMI may not even indicate overweight but the BMI should still be coded if calculated).

I hope that answers your question.

Sighle, RN, soon to be CRC- I hope!
I'm wondering what would be the point of coding BMI as a diagnosis in a patient encounter, if it is not being addressed by the provider? In a procedure, I can see that it may be relevant, but in say a regular office visit would it be appropriate to just enter BMI without mentioning measures to address it?
 

sighle

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The point of coding BMI

I'm wondering what would be the point of coding BMI as a diagnosis in a patient encounter, if it is not being addressed by the provider? In a procedure, I can see that it may be relevant, but in say a regular office visit would it be appropriate to just enter BMI without mentioning measures to address it?
The BMI measurement is a HEDIS quality measure (NCQA) and coding it will get it onto the claims data so that it can be captured for the annual HEDIS review. Coding the BMI, if calculated, should be done even if there's no mention of measures to address it.
 

amla12

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The BMI measurement is a HEDIS quality measure (NCQA) and coding it will get it onto the claims data so that it can be captured for the annual HEDIS review. Coding the BMI, if calculated, should be done even if there's no mention of measures to address it.
Thanks for the info.
 

mamurph34

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coding BMI

Also BMI>40 does risk (HCC 22), so it is important to document it. My organization does as long as the BMI is documented in the chart, even if obesity is not discussed. We are not allowed to calculate it, even if the height/weight is in the chart-it actually has to state BMI xx.
 

kdlberg

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No, BMI can never be the first listed code. The primary diagnosis is the reason the patient is coming in for treatment. They're not coming in for treatment of their BMI. They're coming in for treatment of an associated condition. If the BMI is clinically relevant to the encounter, it should be used as an additional diagnosis.
 

TThivierge

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BMI with Risk Adjustment Coding

No, BMI can never be the first listed code. The primary diagnosis is the reason the patient is coming in for treatment. They're not coming in for treatment of their BMI. They're coming in for treatment of an associated condition. If the BMI is clinically relevant to the encounter, it should be used as an additional diagnosis.
Hi There
BMI dx code should never be first dx code. Also it is associated with RA coding however the physician needs to list a obesity or related dx code needing the BMI listed in record. Cardiac or muscle problems or DM . ..or disease which heavy weight is a no no or need to be monitored,but he or she shld mention patient 's weight monitored. Also when coding BMI dx use 2 dx codes Z68 and E66 blocks according to documentation listed which equals calculated the percentage of adipose on patient's bod ,Etc. on record.

I know some hospitals involved in meaningful use requirements and they want the BMI listed if on the patient's record(a special code put on Medicare claim) but that depends on protocol of your hospital guide from the QA and medical records department.

I hope this info helps

Lady T.
 

bburdett

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It should be noted that the guideline was updated in the 2019 ICD-CM, effective 10/1/18. It now states:

"BMI codes should only be assigned when the associated diagnosis (such as overweight or obesity) meets the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses)."

My understanding is that the diagnosis has to be weight-specific, like obesity/overweight/underweight, not just something that would be affected by weight (which could be practically everything). And it must be an actual codeable diagnosis, not just attention to it.

From an RA perspective, it means we really need those providers to be documented morbid obesity when it's valid. But you can still get that Z68.4* with BMIs over 40 if you can find some mention in the note of the patient being at least overweight or obese.

Also, I believe there's a coding clinic that says obesity always meets the definition of a reportable diagnosis, though with overweight, you need a little more.
 

Pathos

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Also remember bmi of 35 can be morbid as long as there is a comorbity such as hypertension DM ect documented as well.
I have conflicting information regarding your statement of BMI and co-morbidities. Do you have an approved reference to support your claim? Thanks!
 

Jennikate

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What is Morbid Obesity?
Morbid Obesity is a Serious Health Condition
Morbid obesity is a serious health condition that can interfere with basic physical functions such as breathing or walking. Those who are morbidly obese are at greater risk for illnesses including diabetes, high blood pressure, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, osteoarthritis, heart disease, and cancer.
Morbid obesity is diagnosed by determining Body Mass Index (BMI). BMI is defined by the ratio of an individual’s height to his or her weight. Normal BMI ranges from 20-25. An individual is considered morbidly obese if he or she is 100 pounds over his/her ideal body weight, has a BMI of 40 or more, or 35 or more and experiencing obesity-related health conditions, such as high blood pressure or diabetes.
This is from Highland hospital Site. I also confirmed this with Rep from Primecare 3rd party processes our claims for Freedom .
 

Pathos

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Thanks for sharing.

Our organization only uses sources from either the AMA or Coding Clinics to determine our Risk Adjustment policies. So far I have not seen any publications on BMI of 35 and 2+ obesity related health conditions. I have heard of this definition before, but we are pretty conservative on the risk we take on Risk Adjustment. I would like to see more sources on the matter from AMA or AHA (Coding Clinics) on this matter, as this would remove any doubt when CMS comes auditing (because they are seriously ramping up their audits this year!
 
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I'm new at risk adjustment coding, but it seems like sometimes things aren't in clear format. You have to read and get to know all the guidelines to figure out what is allowed. Also, it seems to be who you are risk adjustment coding for, and what they want.

page 94 Z68 (ICD 10 CM guidelines for 2020)-
"Z68 Body mass index (BMI) BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity). Do not assign BMI codes during pregnancy."

I.B.14-
"Documentation by Clinicians Other than the Patient's Provider Code assignment is based on the documentation by patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). There are a few exceptions, such as codes for the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification."
 
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AHA coding clinic (4th quarter 2018)-) These questions don't really answer all your questions, but might help. I'm a new risk adjustment coder, but it seems like who you are risk adjustment coding for depends on what is allowed.)

"The AHA Central Office has received many questions about assigning body mass index (BMI) codes. The following questions and answers are being published in response to many requests for assistance and to clear up any confusion.
Question 1:
Is there a list of diagnosis codes that are associated with the body mass index (BMI) measurement codes? Can BMI codes be assigned without a corresponding documented diagnosis of overweight, obesity or morbid obesity from the provider?
Answer:
No, the provider must provide documentation of a clinical condition, such as overweight, obesity or morbid obesity, to justify reporting a code for the body mass index. As stated in the Official Guidelines for Coding and Reporting, Section I.B.14, the associated diagnosis (such as overweight or obesity) must be documented by the patient’s provider. If the linkage between the BMI and a clinical condition is not clearly documented, query the provider for clarification. ICD-10-CM does not provide definitions or a list of diagnosis codes associated with BMI.
Question 2:
If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only, without any additional documentation to support the clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance for this condition such as evaluation, treatment, increased monitoring, or increased nursing care, etc.
Answer:
Obesity and morbid obesity are always clinically significant and reportable when documented by the provider. In addition, if documented, the body mass index (BMI) code may be coded in addition to the obesity or morbid obesity code.
Question 3:
If the provider documents “overweight” in the history and physical and/or discharge summary only, without additional documentation to support the clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance. Can we also assign the BMI code?
Answer:
No, neither the code for overweight nor the BMI code is assigned if there is no documentation that the diagnosis of “overweight” meets the definition of a reportable secondary diagnosis. While “overweight” may place a patient at increased risk for certain medical conditions, it does not automatically meet the definition of a reportable diagnosis.
For inpatient reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:
  • clinical evaluation; or
  • therapeutic treatment; or
  • diagnostic procedures; or
  • extended length of hospital stay; or
  • increased nursing care and/or monitoring.
For outpatient reporting purposes, as stated in the Official Guidelines for Coding and Reporting, Section IV.J. “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”
Question 4:
Our hospital is receiving denials regarding the coding of BMI and some payors are requiring that it must meet the definition of reportable additional diagnosis and clinically validated regarding body mass. We have interpreted that to mean that something should be documented in the chart regarding weight loss, a special diet, a Hoyer lift, nutrition involved, something regarding loss or gain of weight, and advice to improve the situation revolving around weight. Other sample documentation we use to clinically validate include general weight loss/lifestyle modification strategies discussed (elicit support from others; identify saboteurs; non-food rewards, etc.), or informal exercise measures discussed, e.g., taking stairs instead of elevator. Would these be valid examples to warrant the reporting of BMI as a secondary diagnosis?
Answer:
BMI codes may be assigned whenever an associated diagnosis (such as overweight or obesity) is documented and meets the definition of a reportable diagnosis.
Question 5:
When a patient has a BMI below 40, but morbid obesity is documented by the anesthesiologist (no other documentation regarding the patient’s obesity is recorded in the health record), is it appropriate to code morbid obesity or is a query recommended?
Answer:
Codes for overweight, obesity or morbid obesity are assigned based on the provider’s documentation of these conditions. Therefore, if morbid obesity is documented, assign code E66.01, Morbid (severe) obesity due to excess calories. While the BMI is used as a screening tool for patients who are overweight or obese, there is no coding rule that defines what BMI values correspond to obesity or morbid obesity, since the conditions are coded only when diagnosed and documented by the provider or another physician involved in the patient’s care.
As noted in the Official Guidelines for Coding and Reporting, Section I.A.19, “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” Please refer to Coding Clinic, Fourth Quarter 2016, pages 147-149, for additional information regarding this guideline.
Documentation from physicians other than the attending physician (i.e., consultants, residents, anesthesiologists, etc.) is acceptable, as long as there is no conflicting information from the attending physician."
 
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"
Question 6:
When a patient has obesity related conditions such as diabetes mellitus, obstructive sleep apnea or hypertension, does that affect which code to assign (morbid obesity vs. obesity)?
Answer:
Code assignment for obesity or morbid obesity is based on the provider’s explicit documentation of the condition.
Question 7:
The physician documents a diagnosis of obesity as a pregnancy complication and the patient’s BMI is noted in the record. Is it appropriate to assign a code for the BMI documented on the delivery record?
Answer:
No, do not assign codes for the body mass index (BMI) during pregnancy. Assign only code O99.214, Obesity complicating childbirth, with the specific obesity code from category E66-, Overweight and obesity, for obesity complicating delivery. Weight gain during pregnancy is evaluated differently, and is based on the mother’s BMI before the pregnancy. Please note that effective October 1, 2018, the Official Guidelines for Coding and Reporting for BMI codes have been revised. The revised guideline states, “Do not assign BMI codes during pregnancy.”
Question 8:
There appears to be a discrepancy in the age range for pediatric BMI between the ICD-10-CM classification and the CDC’s growth charts. The note at category Z68, Body mass index [BMI], indicates “BMI adult codes are for use for persons 21 years of age or older. BMI pediatric codes are for use for persons 2-20 years of age. These percentiles are based on the growth charts published by the Centers for Disease Control and Prevention (CDC).” However, the CDC’s pediatric BMI calculator instructs to use the adult BMI calculator for adults, 20 years old or older and the pediatric calculator for children and teens, aged 2 through 19 years old. For a 20-year-old patient with documented obesity, which BMI codes should be used?
Answer:
Follow the instructions in the ICD-10-CM and assign the appropriate code from subcategory Z68.5, Body mass index (BMI) pediatric, for a 20-year-old patient.
Question 9:
Please clarify whether BMI codes may be reported when documented by a physician in his/her office note with or without documentation of an associated diagnosis. The Official Guidelines for Coding and Reporting for codes at category Z68 indicates that these codes should only be assigned when they meet the definition of a reportable diagnosis, which is an inpatient concept. Since there is great interest in collecting BMI data for quality reporting measures, we believe that BMI codes should be reportable if documented as part of the physician/provider authenticated note whether there is an associated condition or not. For example, “The US Preventive Health Services Task Force (USPSTF) recommends that clinicians screen all adults (aged 18 years and older) for obesity.”(Reference: CMS 2016 Group Practice Reporting Option (GPRO) Web Interface Narrative Measure Specifications).
Answer:
No, BMI codes are not intended for routine capture of BMI unless there is provider documentation of an associated diagnosis (such as overweight, obesity or underweight). As stated in the Official Guidelines for Coding and Reporting, Section I.B.14, the associated diagnosis (such as overweight or obesity) must be documented by the patient’s provider. Please refer to the Official Guidelines for Coding and Reporting Section III and Section IV.J for information on reportable diagnoses.
Question 10:
A three-year-old is admitted to the hospital with physical signs of undernutrition and growth rate that was less than the 5th percentile for his age. The physician diagnosed failure to thrive. Would it be appropriate to assign the BMI as an additional code? How should this case be coded?
Answer:
Yes, it is appropriate to assign the BMI code when the patient has an associated diagnosis, such as failure to thrive. Assign code R62.51, Failure to thrive (child), as the principal diagnosis. Code Z68.51, body mass index (BMI) pediatric, less than 5th percentile for age, should be assigned as an additional diagnosis.
Question 11:
Is the BMI measurement assigned as an additional code with diagnoses, such as malnutrition, anorexia nervosa or other eating disorders, cachexia, and abnormal weight loss/gain, when there is no instruction in the Tabular list to use an additional code to identify body mass index?
Answer:
Yes, it would be appropriate to assign the BMI as a secondary code with associated diagnoses such as malnutrition, anorexia nervosa or other eating disorders, cachexia, and abnormal weight loss/gain.
Question 12:
If the provider documents “underweight,” can we assign the appropriate Z code for BMI?
Answer:
If the provider documents “underweight,” the Z code for the documented BMI may be assigned. As stated in the Official Guidelines for Coding and Reporting, Section I.B.14, the associated diagnosis (such as overweight or obesity) must be documented by the patient’s provider. The guideline was not intended to limit the reporting of the Z code for BMI to only overweight and obesity."
 

fwnewbie

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The way I see it, the BMI number is just that, a number. And would relate to dx codes where the number would be used as a tracking tool by the provider, as in anorexia, diabetes, HTN, HF, or any number of health situations where a high BMI is a co-morbidity. Otherwise, it's just a number.
If a provider documents a BP of 175/100, but doesn't document HTN/High BP, we can't code that either can we? It's a number the provider has to use to form their dx and state it as such.
This is just my opinion and I love a good discussion like this!
 
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