Should you code morbid obesity when a patient has a BMI of 36?
This is one of my favorite questions to ask physicians,
coders and healthcare executives when I am teaching. Why? Because it is
guaranteed to elicit the following three responses:
A.
Yes, absolutely! As long as the patient has 3 or
more chronic conditions….
B.
No, I never use that code. I don’t want to upset
anyone with open notes and patient portals…
C.
No, morbid obesity should only be coded with a
BMI of 40.0 or more…
One-third of the audience will select “A” as the correct
answer, one-third will select “B” and one-third will choose “C”. This scenario
will play out the same way in Miami, Philadelphia, Austin, Chicago, Little Rock
or any other city in America. Why? Because it is an urban coding legend…
Urban Coding Legend #1:
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Morbid obesity should always be coded when a patient has a BMI greater than 35.0 and 3 or more chronic conditions.
True
or False?
The answer is false.
Obesity is defined and classified by both the United States Preventive Task
Force and The National Institutes of Health and National Heart, Lung, and Blood
Institute using the following classification:
Obesity is divided into three classes. The third class, extreme obesity,
also called severe obesity, is synonymous with the term “morbid obesity” and is
diagnosed based on a BMI of 40.0 or greater.
According to the NHLBI: A person with a BMI (body mass index) value of 40 or greater would be
considered morbidly obese. An adult who has a BMI of 30 or higher is considered
merely "obese.". Grade 3 overweight (commonly called severe or morbid
obesity) is a BMI greater than or equal to 40 kg/m2.
1.
USPTF
Updates Recommendations
In 2012, the U.S. Preventive Services Task Force (USPSTF) issued
updated recommendations regarding the screening and management of obesity for
adults.
2.
The American
Academy of Family Physicians
The AAFP publishes clinical evidence to support the USPTF Recommendations:
From the AAFP:
In patients with a BMI of
25 kg/m2 or greater, further evaluation of risk factors is required. Blood
pressure and lipid levels should be measured, and fasting glucose tested.
Bariatric surgery may be considered in adults who have
not achieved weight loss with dietary or other treatments and who have a BMI of
40 kg/m2 or greater, or for those who have a BMI of 35 kg/m2 or greater with
significant obesity-related comorbidities (e.g., severe hypertension, type 2
diabetes, obstructive sleep apnea).
Bariatric
surgery may also benefit patients with obesity-related comorbidities who have a
BMI of 35 kg/m2 or lower, but it is not routinely recommended for these
patients
3. Medicare
Payment Guidelines:
In response to
the updated USPTF Guidelines and AAFP clinical evidence supporting the benefit
of gastric bypass surgery as a treatment for obesity Medicare updated their
payment policies for this procedure:
(Rev. 2841, Issued: 12-23-13, Effective:
09-24-13, Implementation: 12-17-13)
Covered Bariatric Surgery Procedures for Treatment
of Co-Morbid Conditions Related to Morbid Obesity
Medicare contractors acting
within their respective jurisdictions may determine coverage of stand-alone LSG
for the treatment of co-morbid conditions related to obesity in Medicare
beneficiaries only when all of the
following conditions are satisfied:
·
The beneficiary has a body-mass index (BMI) ≥ 35
kg/m2;
·
The beneficiary has at least one co-morbidity
related to obesity; and
·
The beneficiary has been previously unsuccessful
with medical treatment for obesity.
4.
Revised HCC
Model
On April 1, 2013 CMS released the Announcement
of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and Medicare
Advantage and Part D Payment Policies and Final Call Letter.
In the Final Call Letter, CMS confirmed that they would be
implementing the updated, clinically revised CMS-HCC risk adjustment model
proposed in the Advance Notice for CY2014. The new model expanded the current number of Condition
Categories from 70 to 79.
Under the revised model, the “Metabolic” category was
expanded from one (HCC 21) to three (HCC 21, HCC 22, HCC 23). Given the
prevalence of obesity, the new HCC 22 “morbid obesity” was quickly identified
as a “low hanging fruit” for optimization teams. By coding morbid obesity with
a BMI of 35.0 vs. 40.0 the prevalence rates, A.K.A. payments, to the plans
would greatly increase.
The previous three events were loosely woven together to
form support for the practice and an urban coding legend rose like a phoenix
from the ashes.
Do you see a BMI under 40 in the above chart?
Remember clinical, coding and payment guidelines can not be substituted to fit the situation as needed. |
