Coding Obesity in ICD-10-CM
Coding Obesity in ICD-10-CM, the documentation should include, the severity such as overweight, obese, or morbid obesity; contributing factors such as excessive calories or drug induced; association such as pregnancy, symptoms, findings, manifestations such as body mass index or alveolar hypoventilation. Obesity means too much of body fat. An obese person is someone who has accumulated body fat that might have a negative effect on their health. If a person’s bodyweight is at least 20% higher than it should be, he or she is considered to be obese. Losing even 5-10 percent of your weight can delay the risks associated with obesity.
Consuming too many calories
Leading a sedentary lifestyle
Not getting enough sleep
Endocrine disruptors such as foods that interfere with lipid metabolism
Medications that help in gaining weight and a faulty gene
BMI plays an important factor in obesity:
BMI (ie) Body Mass Index is a measure of body fat based on height and weight that applies to adult men and women. Obesity is diagnosed when an individual?s body mass index (BMI) is 30 or higher. Body mass index is calculated by dividing weight in kilograms (kg) by height in meters (m) squared.
Category | BMI |
Underweight | Below 18.5 |
Normal | 18.5-24.9 |
Overweight | 25.0-29.9 |
Obesity | 30.0 and above |
Obesity increases the risk of:
- Diabetes
- Heart disease
- Stroke,
- Arthritis and some cancers.
- Bone and cartilage degeneration
- Gallbladder disease
- Hypertension
- High Total Cholesterol
- Respiratory problems
- Sleep apnea
- Stroke
Treatment for obesity:
- Healthy weight
- Maintaining a healthy weight
- Dietary changes
- Physical activity
- Prescription medications for losing weight
- Bariatric surgery or weight loss surgery
Coding Obesity in ICD-10-CM choices include:
- Morbid (severe) obesity due to excess calories E66.01
- Other obesity due to excess calories E66.09
- Drug-induced obesity E66.1
Note: This code contains an instructional note to use an additional code for the adverse effect, if applicable to identify the drug (T36-T50) with fifth or sixth character 5.
- Morbid (severe) obesity with alveolar hypoventilation E66.2
- Overweight E66.3
- Other obesity E66.8
- Obesity, unspecified E66.9
Category E66 contains two instructional notes:
- Code first obesity complicating pregnancy, childbirth, and puerperium, if applicable O99.21
- Use an additional code to identify body mass index (BMI) if known Z68
Below are two examples for coding cases seen for obesity:
Coding Obesity in ICD-10-CM Example 1: The patient is a 45-year-old woman who has gained over 51 pounds in the last 10 years. She sees the physician for medical treatment to help her lose weight. The physician examines the patient and suggests that she tries to lose weight through diet and exercise before prescribing medication. From this encounter it is clear that the physician diagnosed the patient with obesity.
Based on this documentation the patient is diagnosed with obesity; however, there is no documentation about the cause, or of her Body Mass Index. Because of the lack of detail, the correct code for this visit will be E66.9 Obesity, unspecified.
Coding Obesity in ICD-10-CM Example 2: A 52-year-old female is seen for obesity with a 10 year history of type 2 diabetes mellitus.
Her complains are fatigue, difficulty losing weight, and no motivation. She denies polyuria, polydipsia, polyphagia, blurred vision, or vaginal infections.
Since being placed on insulin 7 years ago, she has gained an enormous amount of weight. She eats in excess of 2000 calories a day. However she eats only 3 meals a day but eats a lot of snacks through the day.
On examination, her height is 5?1? and her weight is 265lb, Body Mass Index is 50.1. Her blood pressure is 120/80 mmHg.
Assessment: Morbid obesity, Type 2 diabetes mellitus
Based on this documentation,
- The patient is diagnosed with morbid obesity due to excess calories, Coding in ICD-10-CM as:
E66.01 Morbid (severe) obesity due to excess calories
- The patient has a body mass index of 50.1, which would be coded Z68.43 Body mass index (BMI) 50-59.9, adult
- The patient also has Type 2 diabetes without complication E11.9 Type 2 diabetes mellitus without complications, with long term, current use of insulin Z79.4 Long term (current) use of insulin