obesity
Urban Coding Legends: Morbid Obesity

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:
Morbid obesity should always be coded when a patient has a BMI greater than 35.0 and 3 or more chronic conditions.

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:

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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.

The Origins

This “urban coding legend” originated from the corridors of “risk adjustment optimization” teams, searching for “low hanging fruit” and the clinical evidence to “support” it.

The following events, recommendations and guidelines set the stage and a story was born…


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.

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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:

150.6 – Claims Guidance for Payment

(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.

Remember clinical, coding and payment guidelines cannot be substituted to fit the situation as needed.

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Do you see a BMI under 40 listed in the chart above?

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