Alert coders about new guidance for coding body mass index and pressure ulcers

APRIL 22, 2009 —
Alert coders about new guidance for coding body mass index and pressure ulcers
Hospitals around the country face a new challenge: teaching coders that they can, in certain circumstances, use documentation from nonphysician providers to code pressure ulcer stage and body mass index (BMI).

New guidance, which appears in the updated ICD-9-CM Official Guidelines for Coding and Reporting and Coding Clinic, fourth quarter 2008, took effect October 1, 2008. It gives coders the ability to code the stage, not the site, of a pressure ulcer based on documentation from a nurse or other clinician.

The same Coding Clinic reminds coders that they can code a patient’s BMI using documentation from a dietitian when the BMI has clinical significance to the patient encounter. (Guidance on this topic first appeared in Coding Clinic in 2005.)
In both cases, the patient’s physician—and not a nonphysician provider—must still document an associated diagnosis, such as pressure ulcer site or obesity.

“These are basically like add-on codes,” says DeAnne W. Bloomquist, RHIT, CCS, president and chief consultant at Mid-Continent Coding, Inc., in Overland Park, KS. “You still have to get a diagnosis from a doctor.”

BMI
Although this BMI guidance is new to the official coding guidelines, it is not the first directive issued on the topic. Coding Clinic, fourth quarter 2005, stated that coders could code BMI based on notes from dietitians.

Incorporating this guidance into the official coding guidelines is a positive step toward recognizing the importance of documentation provided by other clinicians, particularly in terms of patient care and data monitoring processes, says Shannon E. McCall, RHIA, CCS, CPC-I, director of HIM and coding at HCPro, Inc., in Chesterfield, VA, and veteran instructor of HCPro’s Certified Coder Book Camp®–Inpatient and Original versions.

“Dietitians routinely would gather [BMI] as part of their analysis,” McCall says. Dietitians also analyze BMI fluctuations (e.g., higher BMI due to extra muscle mass or pregnancy) and understand the BMI’s limitations. For example, the calculation to determine BMI takes into account height and weight, but not muscle mass. Dietitians have an innate ability to use BMI to make judgment calls about medical nutrition therapy, McCall adds.

Coders can use nonphysician documentation of BMI only when the following conditions are met:

The documentation includes physician notation of a clinical condition such as obesity or malnutrition
The BMI has clinical relevance to the patient and meets at least one criterion for a reportable additional diagnosis (i.e., requires clinical evaluation, therapeutic treatment, diagnostic procedures, an extended length of stay, or increased nursing care and monitoring)
When the documentation from the physician and the dietitian don’t match, coders must query the physician.

The latest reminder and inclusion in the official coding guidelines is necessary to counteract recent inappropriate reporting of BMI, Bloomquist says.

“People were just indiscriminately slapping on the BMI codes when the doctor wasn’t documenting obesity,” she says, adding that they were even reporting normal BMIs, which typically have no bearing on patient treatment.

Coders should pay attention to the BMI number because it makes a difference in terms of reimbursement, Bloomquist says. A BMI of 40 or higher—diagnosis code V85.4—is considered a complicating condition, meaning higher reimbursement when coders report this code along with the appropriate principal diagnosis.

The same logic holds true for BMIs under 19. “That’s significantly underweight, so you would want some condition to go with that—malnutrition or even just being underweight,” Bloomquist says.

After Cindy Finnesy, RHIT, CCS, of Newton (KS) Medical Center, read the recent Coding Clinic guidance, she and the HIM director decided their hospital should have a policy delineating when coders could use documentation from dietitians to code BMI.

“We just decided we needed a process for coders to know for sure what to do,” says Finnesy, the assistant HIM director and lead coder at the 103-bed facility. Newton’s policy states that coders will:

Select two appropriate codes when the BMI (documented by a dietitian or physician) and an associated diagnosis (documented by a physician) appear in the medical record
Query the physician in instances when an appropriately documented BMI of under 19 or higher than 40 appears without an associated diagnosis
The policy also states that Newton coders will not:

Code normal BMIs (i.e., 19–24.9).
Query when physicians document BMIs between 25 and 39.9 without an appropriate associated diagnosis. This is intended to prevent coders from overwhelming physicians with queries, Finnesy says.
Document BMIs for anyone under age 20.
Having a facility-specific policy for BMIs has helped create consistency and ensure compliant coding, says Finnesy.

Pressure ulcers
The ICD-9-CM Official Guidelines for Coding and Reporting and Coding Clinic, fourth quarter 2008, also offered guidance about pressure ulcer coding. Coders can assign pressure ulcer stage codes based on documentation from a clinician who is not the patient’s provider (e.g., a nurse). However, the patient’s physician must provide information about the pressure ulcer site.

“It was a logical place to allow a little bit of leniency,” McCall says. “Nurses are … adept at being able to identify the various stages of a pressure ulcer.”

For example, wound care nurses have more experience treating pressure ulcers than do other nurses and physicians, Bloomquist says. Also, during treatment, they more closely measure and monitor an ulcer, documenting its depth and taking pictures to watch its progress.

Although the guidance makes the overall process of coding pressure ulcers slightly easier, it doesn’t prevent the need for physician queries. The official guidelines explicitly delineate a sequence for coding this condition: First, select a site code from diagnosis code range 707.00–707.09. Then select a stage code from diagnosis code range 707.20–707.25. When the physician doesn’t document a site, a coder cannot assign either code.

Codes for pressure ulcers, BMI
Guidance in the ICD-9-CM Official Guidelines for Coding and Reporting and Coding Clinic, fourth quarter 2008, that took effect on October 1, 2008, stated that coders can use documentation from nonphysicians to code pressure ulcer stage and body mass index (BMI). Following are the relevant codes:

Pressure ulcer site

707.00, unspecified site
707.01, elbow
707.02, upper back
707.03, lower back
707.04, hip
707.05, buttock
707.06, ankle
707.07, heel
707.09, other site
Pressure ulcer stage

707.20, unspecified stage
707.21, stage 1
707.22, stage 2
707.23, stage 3
707.24, stage 4
707.25, unstageable
Body mass index

V85.0, BMI less than 19, adult
V85.1, BMI of 19–24, adult
V85.2x, BMI of 25–29, adult
V85.3x, BMI of 30–39, adult
V85.4, BMI of 40 and higher, adult
V85.5x, BMI, pediatric
Editor’s note: DeAnne W. Bloomquist, RHIT, CCS, is the president and chief consultant at Mid-Continent Coding, Inc., in Overland Park, KS. E-mail her at dee@mccoding.com.

Shannon E. McCall, RHIA, CCS, CPC-I, is the director of HIM and coding at HCPro, Inc., in Chesterfield, VA, and veteran instructor of HCPro’s Certified Coder Book Camp®–Inpatient and Original versions. E-mail her at smccall@hcpro.com.

Cindy Finnesy, RHIT, CCS, is the assistant HIM director and lead coder at Newton (KS) Medical Center.

This story originally appeared in the March issue of Briefings on Coding Compliance Strategies.

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