Awareness : Did You Know? 2015-2016

Did You Know? Weekly Educational Series 40

For the Week of July 25, 2016

Morbid Obesity for Bariatric Surgery Patients: A single diagnosis isn’t sufficient justification under ICD-10

“Morbid obesity” might have been your go-to diagnosis for anesthesia during bariatric surgery in the past, but you need more than that to meet today’s requirements.

What you need: ICD-10 coding guidelines stipulate that you report additional diagnoses to further define the patient’s condition. Many payers also require evidence of co-morbid conditions that demonstrate specific ill-health effects of the obesity. If you don’t follow through with these additional requirements, you’ll find yourself with denied claims.

Step 1: Begin with the diagnosis for morbid obesity, as you’ve done before – E66.01 (Morbid [severe] obesity due to excess calories).

Step 2: Select the appropriate code to identify the patient’s body mass index (BMI). For an adult patient, this will come from the range Z68.1 (Body mass index [BMI] 19 or less, adult) to Z68.45 (Body mass index [BMI] 70 or greater, adult). The codes specify BMI in increments of one unit. Many payers have a BMI level below which they will not cover bariatric surgery.

Step 3: Remember that many payers expect you to show that the patient presents with at least one adverse health concern related to obesity. This information should be in the surgeon’s report. A few examples of the types of comorbidities some payers look for as justification for bariatric surgery include:

  • Hypertension — such as I10 (Essential [primary] hypertension)
  • Type II diabetes — E11.- (Type 2 diabetes mellitus…)
  • Coronary heart disease — such as I25.1- (Athero¬sclerotic heart disease of native coronary artery…)
  • Stroke — such as I61.- (Non-traumatic intracerebral hemorrhage…).
  • Other comorbid conditions include gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain types of cancers.