Wiki Class (II, III) Obesity with comorbidity - How many codes to use?

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With the new codes giving specifics to reporting obesity by class, it has led to a situation where our EHR system defaults having providers use multiple codes in a way seeming excessive for example:

Class II Severe obesity with comorbidity BMI 38.92
E66.812 (Class II Obesity)
E66.01 (Morbid Obesity)
Z68.38 (BMI)

The question is if the morbid obesity code should/can be kept as part of that set. I think the old justification was that morbid obesity can be inferred from obesity with comorbidity- which never really sat right with several of us even though payers seemed to want coding for obesity with comorbidity as E66.01 when BMI >35. The whole conditional BMI element was already putting it outside of coding guidelines. This doesn't really feel like "upcoding" but it feels like over coding..

Now that there is a distinct code to report the level of obesity, it seems inappropriate/redundant- only E66.812 & the BMI itself seems compliant.

If you think the acrobatics to extract Morbid Obesity from a statement like Class II Severe obesity with comorbidity BMI 38.92 are appropriate, please let me know why and any examples you can if so! I'm really curious. Right now, tending towards just deleting the second, less specific morbid obesity code since the new ones are more specific.

Of course, for HCC purposes that has an impact on risk adjustment. If you ask the Coding Clinic folks they are quick to clarify that we should only code Morbid Obesity when Morbid Obesity is documented, and that BMI should not be kept in mind when assigning an obesity code (only the BMI code). Three codes seems like a stretch..

Happy V28 2025 fellow risk adjustment coders!!
 
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I have a different kind of question about these new codes. One of my providers asked me about this type of scenario:

The patient was seen for weight loss and during the initial visit, they were in class 2 obesity. Now that they have been using medication to aid with weight loss, they are now below the BMI for obesity even, but they are still on the medication for another few months. Do you keep the diagnosis as the original class 2 obesity as that is what they are treating? Because the condition is still being treated, should it be coded as still present? It certainly makes sense that the condition being treated is improving, but obesity is still a chronic condition.
 
With the new codes giving specifics to reporting obesity by class, it has led to a situation where our EHR system defaults having providers use multiple codes in a way seeming excessive for example:

Class II Severe obesity with comorbidity BMI 38.92
E66.813 (Class II Obesity)
E66.01 (Morbid Obesity)
Z68.39 (BMI)

The question is if the morbid obesity code should/can be kept as part of that set. I think the old justification was that morbid obesity can be inferred from obesity with comorbidity- which never really sat right with several of us even though payers seemed to want coding for obesity with comorbidity as E66.01 when BMI >35. The whole conditional BMI element was already putting it outside of coding guidelines. This doesn't really feel like "upcoding" but it feels like over coding..

Now that there is a distinct code to report the level of obesity, it seems inappropriate/redundant- only E66.813 & the BMI itself seems compliant.

If you think the acrobatics to extract Morbid Obesity from a statement like Class II Severe obesity with comorbidity BMI 38.92 are appropriate, please let me know why and any examples you can if so! I'm really curious. Right now, tending towards just deleting the second, less specific morbid obesity code since the new ones are more specific.

Of course, for HCC purposes that has an impact on risk adjustment. If you ask the Coding Clinic folks they are quick to clarify that we should only code Morbid Obesity when Morbid Obesity is documented, and that BMI should not be kept in mind when assigning an obesity code (only the BMI code). Three codes seems like a stretch..

Happy V28 2025 fellow risk adjustment coders!!
The new codes were created to add specificity and as we are to code to the greatest degree of specificity, I would only code the class II dx and BMI
 
Thank you Cmama12! That's how I interpreted the new codes being integrated as well. Just stick to that is the most specific be it obesity by class or morbid obesity as standalone.

I'm waiting on a code book so to review tabular notes in this year's manual. A colleague mentioned that there's a "code also" instructional note related to coding E66.01 Morbid Obesity with Class III obesity in the section which would complicate things when it comes to the "just code what is specific to it" boundary.
 
I have a different kind of question about these new codes. One of my providers asked me about this type of scenario:

The patient was seen for weight loss and during the initial visit, they were in class 2 obesity. Now that they have been using medication to aid with weight loss, they are now below the BMI for obesity even, but they are still on the medication for another few months. Do you keep the diagnosis as the original class 2 obesity as that is what they are treating? Because the condition is still being treated, should it be coded as still present? It certainly makes sense that the condition being treated is improving, but obesity is still a chronic condition.
I would say that the coding clinic guidance from the AHA is to code the weight related condition as the physician reports it. If a physician reports class 2 obesity, report that code. Don't frame your decisions to select an E## code based on BMI, that is not appropriate for coding professionals per the coding clinic. Coders should simply update the BMI code to match what it charted for that day if an old BMI is used.

The Risk Adjustment coding mentality does mean that if the condition is still being treated, like with a medication, it can have MEAT. Deciding when to change the class on a record is at the physician's discretion. Per this ACDIS article the descriptors in the updated tabular list don't put a BMI boundary on by class:

"You will notice in the ICD-10-CM code set that the BMIs are not part of the code description, nor are they in the inclusion terminology. "

The EHR your practice uses may complicate this since they tend to combine BMI and obesity codes as sets of two or three items with one text descriptor.
 
Thank you Cmama12! That's how I interpreted the new codes being integrated as well. Just stick to that is the most specific be it obesity by class or morbid obesity as standalone.

I'm waiting on a code book so to review tabular notes in this year's manual. A colleague mentioned that there's a "code also" instructional note related to coding E66.01 Morbid Obesity with Class III obesity in the section which would complicate things when it comes to the "just code what is specific to it" boundary.
There is not a "code also"instruction. There is, however, a tip that was in last year's book to code morbid obesity when class 3 obesity is documented, but that was before there was a specific code for class 3. I feel like it was an oversight that it was left in this year, and also if they are saying morbid obesity is synonomous with class 3, now that there is a class 3 code, why still have the E66.01 code? :confused:🤷‍♀️
 
That's interesting. How annoying. The ambiguity around redundancy is what has been bugging me so much about this codeset update.

Thank you so much, I really appreciate the insight!
 
For this documentation "Class II Severe obesity with comorbidity BMI 38.92," I would code E66.01, E66.812, Z68.38. If the provider had not documented the word "severe," I would have only coded E66.812, Z68.38.
My team recently came across documentation where the provider documented "Class 3 severe obesity due to excess calories in adult E66.813" & BMI 40.0-44.9. As you can see, the EMR confused their code selection and already appended E66.813. After careful review, coding selected was E66.01, E66.813, Z68.41.

A couple points:
1. When "due to excess calories" is further specified in the documentation, I would code for either E66.01 or E66.09, otherwise if you omit one of these codes, this would be specified documentation that was undercoded.
2. There is no excludes note under E66.811, E66.812, nor E66.813. There is an excludes note under E66.01, but not about E66.812, E66.813, nor E66.813.
3. The 4th quarter AHA coding clinic about the Obesity class codes did not address the issue we are seeing. However, Q2 2022, class 3 was associated as synonymous with 'severe' (otherwise termed morbid) obesity, but now that there is an actual class 3 code coded as E88.813 that is distinct from morbid obesity, and this is where the confusion is arising.

Go back to the documentation. If 'severe' or 'morbid' or 'due to excess calories' are documented, I wouldn't omit coding either E66.01 or E66.09.

Lastly, Morbid Obesity cannot be inferred. Unless the documentation states Morbid Obesity or Severe Obesity, I would not code E66.01 or E66.2. Any payers messaging to code Obesity with Comorbidity as E66.01 should be directing education about clinical indicators toward providers, not coders. The diagnosis made is per the provider. When I see Obesity documented, I.A.19 is the next step and "the provider's statement that the patient has a particular condition is sufficient." If I saw "Obesity with Comorbidity" documented, I would code Obesity E66.9.
 
By coding only
The new codes were created to add specificity and as we are to code to the greatest degree of specificity, I would only code the class II dx and BMI
By coding only the class II diagnosis, you would be not taking into account the specificity called out in the description. 'Severe' specifies beyond what E66.812 conveys.
 
For this documentation "Class II Severe obesity with comorbidity BMI 38.92," I would code E66.01, E66.812, Z68.38. If the provider had not documented the word "severe," I would have only coded E66.812, Z68.38.
My team recently came across documentation where the provider documented "Class 3 severe obesity due to excess calories in adult E66.813" & BMI 40.0-44.9. As you can see, the EMR confused their code selection and already appended E66.813. After careful review, coding selected was E66.01, E66.813, Z68.41.

A couple points:
1. When "due to excess calories" is further specified in the documentation, I would code for either E66.01 or E66.09, otherwise if you omit one of these codes, this would be specified documentation that was undercoded.
2. There is no excludes note under E66.811, E66.812, nor E66.813. There is an excludes note under E66.01, but not about E66.812, E66.813, nor E66.813.
3. The 4th quarter AHA coding clinic about the Obesity class codes did not address the issue we are seeing. However, Q2 2022, class 3 was associated as synonymous with 'severe' (otherwise termed morbid) obesity, but now that there is an actual class 3 code coded as E88.813 that is distinct from morbid obesity, and this is where the confusion is arising.

Go back to the documentation. If 'severe' or 'morbid' or 'due to excess calories' are documented, I wouldn't omit coding either E66.01 or E66.09.

Lastly, Morbid Obesity cannot be inferred. Unless the documentation states Morbid Obesity or Severe Obesity, I would not code E66.01 or E66.2. Any payers messaging to code Obesity with Comorbidity as E66.01 should be directing education about clinical indicators toward providers, not coders. The diagnosis made is per the provider. When I see Obesity documented, I.A.19 is the next step and "the provider's statement that the patient has a particular condition is sufficient." If I saw "Obesity with Comorbidity" documented, I would code Obesity E66.9.

Disagree with coding obesity class and E66.01. The first link from ACDIS specifically addresses these questions, which is the rationale we are following pending any further clarifications from Coding Clinic. The link from the CDC speaks to the intent of the new codes in improved accuracy of obesity coding.

https://acdis.org/articles/qa-new-‘other-obesity’-codes

https://www.cdc.gov/obesity/media/p...tner-Promotion-Materials-ICD-10-Codes-508.pdf
 
Leanne - I see what you mean by coding for E66.01 when severe obesity is mentioned due to the existing (pre 2025) clarification on severe and morbid being more or less interchangeable. That's what the manuals have said for some time now. It has been common practice to do either E66.09 or E66.01 depending on the language used when a provider documents obesity using by class. Seems to stem from some of that payer-driven guidance when it comes to documentation (and coding) based off of class. If I understand correctly, your organization finds 'severe' to be more specific language than the language about obesity by class (or equally relevant).

IMO the by class codes are more specific to a note like Class II Severe obesity with comorbidity BMI 38.92 than a morbid obesity or severe obesity. Of course we shouldn't be querying providers to clarify if a patient has Class II obesity or morbid obesity (in particular since the EMR/EHR usually pushes providers to document in those long [Class II w/ comorbidity and BMI..]. strings). I don't want to go with the a condition that leans to a higher RAF if it is ambiguous. Class III severe is easy, reporting E66.813 and Z68.42 makes the E66.01 irrelevant for the RAF contribution anyway since BMI>40 always picks one up. Adding E66.01 is, however, a way to make a diagnosis of Class II severe (like E66.812 & Z68.39) into an HCC diagnosis. Maybe I'm being overly cautious only trying to report 2 codes.

Hopefully coding clinic clarifies! It is ambiguous how many concurrent codes CMS and the AHA consider appropriate. Like you point out, there's no explicit excludes note separating them from each other. I generally only want to report one code, the most specific to each category, so only one E66####. BMI is a whole different set of rules. Obesity by class now that they are introduced seem like a better match, which would follow the ACDIS guidance referred to above. Hopefully CMS will be forgiving on Y25 audits since there's so much ambiguity around what is ok.
 
Leanne - I see what you mean by coding for E66.01 when severe obesity is mentioned due to the existing (pre 2025) clarification on severe and morbid being more or less interchangeable. That's what the manuals have said for some time now. It has been common practice to do either E66.09 or E66.01 depending on the language used when a provider documents obesity using by class. Seems to stem from some of that payer-driven guidance when it comes to documentation (and coding) based off of class. If I understand correctly, your organization finds 'severe' to be more specific language than the language about obesity by class (or equally relevant).

IMO the by class codes are more specific to a note like Class II Severe obesity with comorbidity BMI 38.92 than a morbid obesity or severe obesity. Of course we shouldn't be querying providers to clarify if a patient has Class II obesity or morbid obesity (in particular since the EMR/EHR usually pushes providers to document in those long [Class II w/ comorbidity and BMI..]. strings). I don't want to go with the a condition that leans to a higher RAF if it is ambiguous. Class III severe is easy, reporting E66.813 and Z68.42 makes the E66.01 irrelevant for the RAF contribution anyway since BMI>40 always picks one up. Adding E66.01 is, however, a way to make a diagnosis of Class II severe (like E66.812 & Z68.39) into an HCC diagnosis. Maybe I'm being overly cautious only trying to report 2 codes.

Hopefully coding clinic clarifies! It is ambiguous how many concurrent codes CMS and the AHA consider appropriate. Like you point out, there's no explicit excludes note separating them from each other. I generally only want to report one code, the most specific to each category, so only one E66####. BMI is a whole different set of rules. Obesity by class now that they are introduced seem like a better match, which would follow the ACDIS guidance referred to above. Hopefully CMS will be forgiving on Y25 audits since there's so much ambiguity around what is ok.
Not sure if this helps but the April 2025 ICD-10-CM guidelines include the following.
The obesity class codes in subcategory E66.81, Obesity class, require a fifth character to convey the severity of obesity. The obesity class should be documented in the medical record by the provider for these codes to be assigned. The obesity class codes can be reported with other obesity codes in the classification found in Chapters 4 and 15 to fully describe the condition. However, if both class 3 obesity and morbid obesity are documented, only a code for class 3 obesity should be assigned as it is more specific.

Cindy
 
Not sure if this helps but the April 2025 ICD-10-CM guidelines include the following.
The obesity class codes in subcategory E66.81, Obesity class, require a fifth character to convey the severity of obesity. The obesity class should be documented in the medical record by the provider for these codes to be assigned. The obesity class codes can be reported with other obesity codes in the classification found in Chapters 4 and 15 to fully describe the condition. However, if both class 3 obesity and morbid obesity are documented, only a code for class 3 obesity should be assigned as it is more specific.

Cindy
Thanks Cindy, very helpful. Sounds like they WILL be okay with multiple E66 codes. Leaving this below for reference- looks like CMS will put out the full pdf of updated guidelines April 1st 2025 out sometime later this month.

 
CMS still hasn't published the April 1st updates on their website, but it is now available through the CDC:


I think my org is going to stop reporting E66.01 when MD's write by class, per this official guidance. Since the actual publishing of this seems to be up in the air (it still shows on the CMS website as "coming soon") hard to say how it would be judged in an audit. Happy coding everyone!
 
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