Coding for Morbid Obesity

Question:

When the BMI is 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.


AHA Coding Clinic, Fourth Quarter 2018, pp. 79 – 80


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Coding for Prescription Pain Medication

Question:

Medical record documentation indicates the patient is taking opioids prescribed by their physician for treatment of chronic pain. Does Guideline I.C.5.b.3. mean that codes cannot be assigned for the opioid use unless there is documentation of an associated physical, mental or behavioral disorder?

Answer:

A code for the use of prescription opiates would not be reported because there is no associated physical, mental or behavioral disorder.


 – AHA Coding Clinic 2018 2nd Quarter, pages 11 and 12


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Coding for Recreational Marijuana Use

Question:

Should recreational marijuana use be coded when documented by the patient’s provider?

Answer:

No, a code for the marijuana use is not assigned unless the provider documents an associated physical, mental, or behavioral disorder in accordance with ICD-10 Guideline I.C.5.b.3.

This guideline states “As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.”


– AHA Coding Clinic 2018, Second Quarter, page 11


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