To Code or Not to Code? 

A Talk Ten Tuesdays listener recently sent me a question that encouraged a dialogue between us. The question was “can obesity class 3 be assigned the code for morbid obesity?”

I had to do a little research, as I did not know the answer immediately. After reviewing the Index of ICD-10-CM and the Tabular to ensure that there were not instructional notes, my next stop was to look up the topic in the American Hospital Association’s (AHA’s) Coding Clinic. A search of that reference did not yield any results. Next stop was the Internet. I did find some discussion about obesity classes on MedlinePlus. There are four levels of obesity, based on Body Mass Index (BMI), which are:

• Overweight – BMI 25.0-29.9
• Class 1 – BMI 30.0-34.9
• Class 2 – BMI 35.0-39.9
• Class 3 – BMI > = 40.0

These classes are not currently referenced in the ICD-10-CM classification, and there is no official coding guidance regarding this topic. So, would you code morbid obesity or not?

Coders are frequently faced with this question as they notice a new procedure or diagnosis. How do they resolve the conundrum? Here are some suggested steps to resolve the “code, or not to code?” situations:

First, review the ICD-10-CM or ICD-10-PCS Index/Tabular. Is the new diagnosis or procedure in the actual classification? Is there something that is close? Do not forget to look at the body part key or substance key for ICD-10-PCS.

Second, analyze the Official Coding and Reporting Guidelines for ICD-10-CM/PCS. Is the scenario mentioned in the guidelines? Keep in mind that the classification coding instructions supersede the guidelines.

Third, another official resource is the aforementioned AHA Coding Clinic. Is the topic included in Coding Clinic? The resource was begun in 1985 and continues today. There have been many topics discussed over the years.

Fourth, facility-specific coding guidelines may address emerging topics until there is official coding guidance. For example, your facility guidelines may cover how codes for COVID-19 routine testing are handled while we are in the pandemic. The official coding guidance is lacking regarding how to handle routine testing of patients who are presenting for procedures and do not have any known exposure. These facility-specific guidelines may also address new substances that qualify for the New Technology Add-On Payment (NTAP). The substances used by a facility may be addressed in these guidelines, as well as where the documentation is located.

Another topic that is problematic for coders is which procedures are coded by health information management (HIM) coders and which are hard-coded (i.e. part of the chargemaster). The guidelines should address which procedures are to be coded by HIM coders, such as insertion of midline catheters, hemodialysis, radiation therapy, chemotherapy, etc. The guidelines should also specify which documentation is the source of truth, especially where there is a conflict.

If the answer is not found in the above steps, the last step would be to send the question to Coding Clinic for resolution. Until the question is answered, the coder must decide “to code or not to code.”

Resources:

https://medlineplus.gov/ency/patientinstructions/000348.htm

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf