Coding, Classification & Reimbursement

Pediatric Gastric Sleeves

  • 1.  Pediatric Gastric Sleeves

    Posted 05-31-2018 15:27
    Hi All!  Would love here if anyone is having issues coding and billing for pediatric gastric sleeves?  One of our clients just started performing gastric sleeves on patients under 21 and ICD-10 requires a pediatric BMI percentile code for patients 2-20 years of age based on CDC growth charts.  The bariatric surgeons are only providing adult BMI information and we can't use it.  Does anyone have a work-around for this issue?  We have queried, explained, begged, pleaded, but not getting any closer to receiving documentation for pediatric BMI percentile on these cases.

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    Amber Owens
    Certified Coding Specialist
    New Jersey Hospital Association
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  • 2.  RE: Pediatric Gastric Sleeves

    Posted 05-31-2018 15:47
    ​Hi Amber,

    Unless the rules have changed, I believe that "clinicians" or clinical staff, such as dietitians or nurses involved in the care of the patient, can document the BMI as well.  However, I believe that the provider has to make a correlation between obesity and BMI.

    If you do not have documentation that support the services, don't bill it.  You could be setting yourself up for fraud (and violation of False Claim Act) by sending out claims that would not support medical necessity of the services.  Remember, fraud is "Knowingly presenting, or causing to be presented a false claim for payment or approval."  So, I would not "game" the system by finding a "work around."

    Any other thoughts?

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    William Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
    AHIMA Approved ICD-10 CM/PCS Trainer
    Compliance Analyst
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  • 3.  RE: Pediatric Gastric Sleeves

    Posted 06-01-2018 01:18
    What about getting a dietician at your facility to document the pediatric BMI? As long as the physician documents obesity, the BMI could be coded from the dietician's documentation.

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    Ashley Sparks
    HIM Coding Quality Coordinator
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  • 4.  RE: Pediatric Gastric Sleeves

    Posted 06-01-2018 06:20
    Hi:
    I think you may not be getting that information because you don't need it. The only medical necessity that I can find is for BMI (>35 with an obesity related co-morbidity or >40). By definition, a child/teen would be off the charts with a BMI in this range. So, there would not be a need to even report with a diagnosis of obesity with a co-morbidity or morbid obesity.
    Just for you to see, go to the growth charts and see where the BMI compares to the growth percentile- the 97th percentile (the highest) stops at a BMI of 32.3 for the age of 20 for boys and declines the younger the child is. For girls the cut-off is BMI of 35. I am not saying to use this in your coding, but just for your information. Or, ask a registered dietitian to help you! Curious if you have seen any denials without submitting the percentile?

    https://www.cdc.gov/growthcharts/data/set3/chart-16.pdf
    https://www.cdc.gov/growthcharts/data/set3/chart-15.pdf

    Here is the main reference page:
    https://www.cdc.gov/growthcharts/charts.htm


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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System
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  • 5.  RE: Pediatric Gastric Sleeves

    Posted 06-01-2018 06:38
    One other thought on this: the tabular under E66 states to code BMI with overweight and obesity if known. So, from a coding perspective, it would be acceptable not to code the pediatric BMI if you don't know it. And the highest pediatric BMI for reporting is > or = 95th percentile.

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System
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  • 6.  RE: Pediatric Gastric Sleeves

    Posted 06-02-2018 08:59
    Edited by Lawrence Barr 06-02-2018 09:04
    ​Hello!

    First of all, the patient is going to have to meet criteria for any type of bariatric surgery which usually includes the current BMI.  You really need to assign the proper BMI.  If an adult BMI is assigned to a pediatric patient you can use the following: Body Mass Index BMI (BMI) Percentile Calculator for Child and Teen | DNPAO | CDC..  As long as the provider documents "morbid obesity" and height, weight, age, and gender, the correct BMI can be calculated by anyone using this tool.  I have used this at multiple facilities with no problem.  In cases involving bariatric surgery, "morbid obesity" has to be documented and unless there are strange circumstances must be assigned as the PDX.

    You may want to pass this calculator along to dieticians and the surgeons who perform the procedure.  It is very simple to use and takes very little time.

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    Lawrence Barr
    President
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  • 7.  RE: Pediatric Gastric Sleeves

    Posted 06-02-2018 10:19
    Hi Lawrence:
    So, I am assuming that you are reporting the pediatric BMI percentile less than the 95th at times for bariatric procedures? That doesn't make sense to me- as per CDC:
    Body mass index (BMI) is a measure used to determine childhood overweight and obesity. Overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex. Obesity is defined as a BMI at or above the 95th percentile for children and teens of the same age and sex.
    Defining Childhood Obesity | Overweight & Obesity | CDC

    Also, as per guidelines, the way I understand it, we can use documented BMI from other providers- there is nothing stating that we can calculate BMI ourselves. Under General Coding Guidelines # 14 documentation for BMI, etc "...code assignment may be based on medical record documentation from clinicians who are not the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). So, I don't believe a coder would fall under this category.​

    Wondering if you could create some sort of policy signed off by the surgeons/dietitians delineating that if a calculated BMI of ~31 for a 95th percentile or greater, that you would be given permission to go ahead and assign the Z68.54 code for the pediatric patients?

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System
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  • 8.  RE: Pediatric Gastric Sleeves

    Posted 06-03-2018 09:26
    ​Hello!

    The assumption is totally incorrect.

    First, the attending provider must document "morbid obesity" which I clearly stated in my original post.  Therefore, the pediatric BMI must meet the criteria for performing the procedure.  Actually, there are more criteria than just the BMI that must be met in order to justify pediatric bariatric surgery.

    If the calculated BMI does not meet the minimum guidelines, then the surgery performed would be deemed unnecessary.  That is a quality/utilization issue.  In my opinion, failure to report the pediatric BMI would constitute a violation of coding ethics by omission.

    I also stated that the individual data elements used to calculate the pediatric BMI also must be documented by the provider. The calculator is provided by The CDC.  Whoever uses the calculator using the correct information will get the same answer.

    I failed to mention I did not come up with this approach on my own. It has also been approved as policy by the coding department.  I have never used the calculator and received a BMI value that did not meet criteria.

    A code for adult BMI will not pass edits for patients under 21 years of age.  When the correct BMI is not documented there are two choices.  Either hold the record for billing and wait for the attending provider or a dietician to calculate the correct BMI or allow the coder to calculate the BMI and process the claim in a timely matter.  The facilities I have coded for have chosen the later.  For one thing, it cuts down on the problem of query fatigue.

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    Lawrence Barr
    President
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  • 9.  RE: Pediatric Gastric Sleeves

    Posted 06-09-2018 10:52
    I don't think it is appropriate for a coder to calculate the BMI themselves to assign a code.  Coding is based on the documentation in the chart.

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    Chrystel Barron
    Coding Education Instructor
    Cleveland Clinic Health System
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  • 10.  RE: Pediatric Gastric Sleeves

    Posted 06-10-2018 07:33
    ​Hello!

    As previously stated, the Pediatric BMI is calculated using variables documented in the chart.

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    Lawrence Barr
    President
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  • 11.  RE: Pediatric Gastric Sleeves

    Posted 06-13-2018 12:34
    I still think it is only appropriate if the BMI itself is documented.  I do not agree with coders making calculations to assign a code.

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    Chrystel Barron
    Coding Education Instructor
    Cleveland Clinic Health System
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  • 12.  RE: Pediatric Gastric Sleeves

    Posted 06-13-2018 12:45
    Also, see Coding Clinic 4th Q 2005 pg 96-98 which specifically states " Coders should not calculate the BMI."

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    Chrystel Barron
    Coding Education Instructor
    Cleveland Clinic Health System
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