Coding, Classification & Reimbursement

Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

Jennifer Hoffman, Health Information Management10-09-2018 14:47

  • 1.  Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-07-2018 14:34
      |   view attached
    Hello AHIMA members,

    My husband is an ER physician and is searching for some guidance and answers about a form posted on the wall next to his computer station in the Emergency Department. I was a medical coder for ten years, but I am no longer working as I go to school for an RHIA.
    In my opinion, the posting of this form should go against hospital policy because it doesn't validate where, why, and who posted this guideline. There is no contact info for anyone who might have questions or concerns. There also isn't any citation to the "new obesity coding guidelines". I find it alarming that uncertified protocols of any type are expected to be followed blindly in a healthcare facility. Doing so could put the facility, staff, and patients at risk.
    First, I tried to research new coding guidelines for obesity but did not find any substantial information. Do you have any clarification on this? I can't tell if they are trying to impact reimbursement but from my understanding, an obesity diagnosis doesn't change the weight of reimbursement but 'morbid/severe obesity' does. That in mind, the form does not seem to be educating the physicians about that, so I do not understand the motivation. The ER physicians interpret the form that they must find reasons to correlate an impact of obesity and the patient's care. I feel this form is guiding ER physicians to document incorrectly, report false manifestations, and require them to address a health issue regardless if their medically-trained opinion finds it unrelated to their encounter. Do you have guidance on handling this?
    Secondly, how are updated guidelines and policies taught to your physicians? What is a proper protocol or standard used to ensure correct distribution and verified information so best practices are followed in a healthcare facility?

    ------------------------------
    Christina Dalton
    ------------------------------


  • 2.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-08-2018 10:21
    ​Hello,

    Please see this reference:

    Clinical significance of obesity
          ICD-9-CM Coding Clinic, Third Quarter 2011 Pages: 3-4 Effective with discharges: September 23, 2011

    ------------------------------
    Stacie Coy
    ------------------------------



  • 3.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-08-2018 10:29
    Christina

    When I read this posting from a coding standpoint it is a reminder that if obesity is affecting the care of the patient it is ok to use this as a diagnosis. In order for obesity to be diagnosed you need to have a reason that you are coding for it - how is the obesity affecting the patient's care or treatment provided and it needs to be documented in the medical record. I haven't seen any guidelines changes for obesity recently and morbid/severe obesity is a HCC code which can affect reimbursement I believe. I am in a Critical Access Hospital so we are paid differently but it does affect HCC in our clinic which affects the physician fee schedule eventually. I do agree that whomever posted this should have their name or department listed for questions or concerns.

    When there are new changes I provide education to my providers with a HIM Newsletter that I prepare or discuss with them at a practitioner meeting that is held monthly. If it is something specific to a certain provider I talk with them directly one-on-one. Sometimes it is hard to get a providers attention as they are so busy but good providers will listen to you and you need to have citations ready for them. I have posted information before but it is general reminders - sign off on your documentation, orders, etc.

    Good luck on your studies.

    ------------------------------
    Beth Kosman, RHIT, CCS, CCS-P
    HIM Director
    Ringgold County Hospital
    ------------------------------



  • 4.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-08-2018 12:32
    I think this guidance is stemming from an actual change in BMI diagnosis (Z68) reporting effective 10/1/2018 and yes, there should be more authoritative information on the sign posted by the computers..

    Section I. C. 21. 3)
    Z68 Body mass index (BMI)

    BMI codes should only be assigned when the
    associated diagnosis (such as overweight or
    obesity) meets the definition of a reportable
    diagnosis (see Section III, Reporting Additional
    Diagnoses). Do not assign BMI codes during
    pregnancy. See Section I.B.14 for BMI
    documentation by clinicians other than the
    patient's provider.



    Section III. Reporting Additional Diagnoses
    GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
    For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions
    that affect patient care in terms of requiring:
    clinical evaluation; or
    therapeutic treatment; or
    diagnostic procedures; or
    extended length of hospital stay; or
    increased nursing care and/or monitoring.
    The UHDDS item #11-b defines Other Diagnoses as "all conditions that coexist at the time of
    admission, that develop subsequently, or that affect the treatment received and/or the length of
    stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital
    stay are to be excluded." UHDDS definitions apply to inpatients in acute care, short-term, long
    term care and psychiatric hospital setting. The UHDDS definitions are used by acute care shortterm
    hospitals to report inpatient data elements in a standardized manner. These data elements
    and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp.
    31038-40.


    ------------------------------
    Rhonda Drinnon
    Coder, Cpc
    ------------------------------



  • 5.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-09-2018 08:42
    Edited by Lawrence Barr 10-09-2018 08:46
    ​Hello!

    I think it is worthwhile to post the actual advice published in Coding Clinic, 3rd QTR 2011, pages 4-5 as referenced by another contributor to this topic.  "Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented. Refer to Coding Clinic, Third Quarter 2007, pages 13-14, for additional information on coding chronic conditions."  The 3RD QTR 2007 Coding Clinic is also a useful reference.  "If there is documentation in the medical record to indicate that the patient has COPD, it should be coded.  Even if this condition is listed only in the history section with no contradictory information, the condition should be coded.  Chronic conditions such as, but not limited to, hypertension, Parkinson’s disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation."

    The most recent release of The Guidelines continues to state the following, "However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient's provider.  The only significant change is the addition of The Guideline to NOT assign BMI codes in obstetric patients.  This went into effect with discharges of October 1, 2018 and thereafter.

    I recently had a similar problem during a recent assignment.  An auditor was obviously not aware of the 2011 or 2007 Coding Clinics.  In most situations certain chronic conditions may be coded strictly based on the provider's documentation of those conditions.  An example of an exception would be if a patient with "obesity" listed as a condition is documented with having undergone successful bariatric surgery.  In that case. the s/p bariatric surgery would be coded but NOT the obesity.  The patient is no longer obese.

    There are no subsequent Official Guidelines nor Official Advice which supersede the cited Coding Clinics.

    ------------------------------
    Lawrence Barr
    President
    ------------------------------



  • 6.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-09-2018 14:47
    FY 2019 ICD-10 Code Changes Overview | Journal of AHIMA
    Journal of AHIMA remove preview
    FY 2019 ICD-10 Code Changes Overview | Journal of AHIMA
    Tune in to this monthly online coding column, facilitated by AHIMA's coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS. By now, everyone should be aware that the fiscal year (FY) 2019 ICD-10 code changes have been released. There are not as many changes this year as there have been in previous years.
    View this on Journal of AHIMA >


    ------------------------------
    Jennifer Hoffman
    Health Information Manager
    ------------------------------



  • 7.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-10-2018 08:08
    Edited by Laurie Zawiskie 10-10-2018 08:11
    Thank you, Jennifer. That is a very interesting article. I wonder how the coder is supposed to determine if obesity meets the definition of a reportable diagnosis. There may be additional resources/equipment that are needed due to the obesity, but the coder may not know that. Maybe this is why the note was posted in the ER. They want the physician to document those resources, so the coder knows it is a reportable diagnosis. As the coder, we should stop routinely coding obesity/bmi unless the physician documents extra resources, the current impact is has on the patient's condition or the reason a surgery is more difficult, etc?

    ------------------------------
    Laurie Zawiskie
    Coder III
    ------------------------------



  • 8.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-11-2018 05:25
    This message was sent securely using Zix®

    Overweight or obesity is coded only if documented by the physician. If the physician documents it, it is a reportable diagnosis.

     

    Brenda Mohs, RHIT

    Home Health & LTC Medical Coder

    Essentia Health

    Brenda.Mohs@Essentia Health.org

     




    This message was secured by Zix®.





  • 9.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-10-2018 10:03
    Edited by Lawrence Barr 10-10-2018 10:12
    ​Hello!

    It is my understanding that the only official sources for coding guidance are The Classification, The Official Guidelines, and Coding Clinic advice.  I am not aware that The Journal of AHIMA has been added to this list.

    Per 4th QTR 2016 Coding Clinic, ""The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis."

    The 2019 update to The Official Guidelines states, "...the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient's provider."  The Official Guidelines regarding the assignment of additional diagnoses state, "The UHDDS item #11-b defines Other Diagnoses as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.  The 3RD QTR 2011 and 3RD QTR 2007 Coding Clinics specifically advise that certain chronic conditions, with limited exceptions, should always be coded.  Additionally, when the patient is examined for the H&P they are undergoing a "clinical evaluation".  This usually includes both a subjective evaluation by the examiner and the objective recording of both height and weight.  Based on this "clinical evaluation", the provider establishes and documents the appropriate diagnosis. According to all the official sources no other information is required to assign the appropriate code.

    Coders are being told to assign codes based on provider documentation.  We are told we do not possess the expertise to perform clinical review.  Then we are told we are supposed to be able to perform clinical review.  We are given contradictory official advice to follow.  It appears to me that certain auditors and "expert organizations" are making up there own guidelines contrary to the official guidelines.  I believe these entities are applying their own personal interpretation of these guidelines out of ignorance of established guidelines or applying the guidelines in a selective manner for their own purposes.

    Based on the official guidelines and advice, a provider's statement that a patient has a condition is sufficient and all conditions that coexist at the time of admission are codable.


    ------------------------------
    Lawrence Barr
    President
    ------------------------------



  • 10.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-10-2018 15:15
    ​Hello Again!

    Well since this morning the 4th QTR 2018 Coding Clinic was released and this topic was again discussed.  The answer agrees with the prior cited Coding Clinic.  "Obesity and morbid obesity are always clinically significant and reportable when documented by the provider. In addition, if documented, the body mass index (BMI) code may be coded in addition to the obesity or morbid obesity code."

    This does not apply to the term "overweight" which must meet the UHDDS definition.  "...neither the code for overweight nor the BMI code is assigned if there is no documentation that the diagnosis of "overweight" meets the definition of a reportable secondary diagnosis.".  Although I do not understand how a physician can document a diagnosis without performing a "clinical evaluation".  Also, in a subsequent answer in the current Coding Clinic they state, "Codes for overweight, obesity or morbid obesity are assigned based on the provider's documentation of these conditions."  So we get a contradiction on the very next page of the same issue.

    Ironically, there is also a discussion in the 4th 2018 regarding conflicting Coding Clinic advice.  Without going into detail, I found the response somewhat "amusing".  However, there was also a response to a question regarding failure to adhere to the "hierarchy" of official coding advice that I found most useful.  "Advising coders to disregard Coding Clinic because of differences in understanding or personal interpretation may be construed as an ethical issue. " 

    ------------------------------
    Lawrence Barr
    President
    ------------------------------



  • 11.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-11-2018 08:03
    Lawrence,

    Thank you for the Coding Clinic update. Maybe the person in the ER read the Journal of AHIMA article?

    ------------------------------
    Laurie Zawiskie
    Coder III
    ------------------------------



  • 12.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-11-2018 11:28
    I agree with everything that Lawrence said.

    ------------------------------
    Chrystel Barron
    Coding Education Instructor
    Cleveland Clinic Health System
    ------------------------------



  • 13.  RE: Physicians received unclear, anonymous, and unverified posting for new obesity guidelines

    Posted 10-11-2018 05:35
    All his questions should be referred to the HIM Department as they as responsible for any guidelines that has to do with medical coding and also the hospitals compliance officer. It's good that he has asked questions about this policy. Is there a way you can have him take a picture of this new policy and hopefully we can shed light on what the heck the hospital is doing incorrectly? The HIM (Health Information Management) Dep should know what's going on and should shed light on what these notices are for. I would hit them up first to ask questions about these "ghost" notices. Physicians are not coders and only responsible for the care of patients and proper documentation of diagnosis and procedres that were rendered to the patients. I hope he gets his answers to this notices for clarification.

    --
    Sincerely,


     
    Charisse Simon, CCS/CPC
    (Certified Medical Coder/Consulting Auditor/ AHIMA ICD 10 CM/PCS Trainer)


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