Wiki Pregnancy and Obesity

[nelamaria]

My providers will add dx O99.21-0,1,2,3 with the E66.9 for a prenatal visit and usually when the BMI it's more than 30% But there it's no documentation from the provider mentioning spoke with patient about obesity or nutrition or if the obesity it's complicating the Pregnancy, or any other conditions complicated by obesity. I have approached the providers but their answer it's the BMI it's on the note and don't have to add extra add documentation. What should I do as a coder?

 

[carlystur]

If they want to get the credit for including it as a diagnosis code, it first needs to affect their care/treatment/management of the patient for that specific visit and there should be documentation reflecting how it affects their care.

Our ICD-10-CM coding guidelines for this year specifies at the start of Section IV.J. that:

Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management.

They need to understand that these are technically legal documents and most likely will be viewed by another provider, who does not know the status of the patient, or I think even a health insurance rep. They should be as specific about their care of each patient as necessary to fully reflect the status of the patient in their documentation. It is on the providers if they do not do this accurately.
While a quick Google search can easily tell you how obesity could affect a patient's pregnancy, I don't believe that would be a good enough reason to include the code on a claim when the provider doesn't specify how a co-existing condition (such as BMI) could affect it.

EDIT: Just realized I didn't really answer your question as fully as I could have. Can you inform your practice manager or a manager about this, if you haven't already? Maybe see if you can get their help in making your providers understand the issue. That's what I had to do at my last workplace.