Obesity (ICD-9-CM code 278.00) is defined as “an
increase in body weight beyond the limitation of skeletal and physical
requirements as the result of excessive accumulation of body fat”
(Dorland’s Medical Dictionary). In adults, a
Body Mass Index (BMI) of 30 or more is considered obese; 60 million
Americans are considered obese, which equates to one in every three
adults. Morbid obesity (AHA Coding Clinic for ICD-9-CM
278.01) is diagnosed when the patient weighs two or more times the
ideal body weight, when the patient is more than 100 pounds above
the ideal body weight, or when the BMI is 40 or more. Six million
Americans are considered morbidly obese. It is called “morbid”
obesity because it is associated with so many life-threatening diseases.
“Mortality and morbidity from most diseases, accidents, and
injuries are significantly higher among obese persons and increase
with the magnitude of the obesity” (The Merck Manual,
16th edition, page 984).
Some conditions associated with obesity are the
following:
• hypertension (401.9)
• type 2 diabetes mellitus (250.x0)
• coronary artery disease (414.0x)
• hypercholesterolemia (272.0)
• osteoarthritis (715.xx)
• stroke (436)
• gallstones (574.20)
• sleep apnea (780.57)
• cancer
Bariatric surgery
If a patient has tried diet and exercise but still has a BMI of
40 or more, then weight-loss (bariatric) surgery may be an option.
There are two main types of gastric surgery for morbid obesity:
restrictive operations and malabsorptive operations. A restrictive
operation restricts the amount of food the stomach can hold. It
involves creating a small pouch at the top of the stomach where
food enters from the esophagus. It thus delays the emptying of food
from the stomach and causes a feeling of fullness; however, it does
not interfere with the normal digestive process. The following are
common restrictive procedures:
• Adjustable gastric banding: A hollow band is placed around
the stomach near its upper end, creating a small pouch and a narrow
passage into the remainder of the stomach. Salt solution is then
used to inflate the band. The band may be tightened or loosened
by adjusting the amount of salt solution in the band. Assign code
44.69 for this procedure.
• Vertical banded gastroplasty: Both bands and staples are
used to create a small stomach pouch. The surgeon divides the stomach
into upper and lower sections by using a surgical stapler. At the
small opening between the two portions of stomach, the surgeon wraps
the tissue with a nonexpandable plastic. Assign code 44.69 for this
procedure.
• Gastric stapling (44.69) uses horizontal staples to divide
the stomach into a tiny upper pouch and large lower pouch with a
dime-sized opening.
• Laparoscopic banding (44.69) uses a band instead of staples
to partition the stomach into two parts. The band is wrapped around
the upper part of the stomach and pulled tight, creating a tiny
channel between the two pouches. The band keeps the opening from
expanding. Do not assign a separate code for the laparoscope since
it is considered the operative approach.
Malabsorptive operations combine stomach restriction
with a partial bypass of the small intestine. Such an operation
makes a direct connection between the stomach and a lower segment
of the small intestine resulting in a decrease in the number of
calories and nutrients absorbed. The following are some common malabsorptive
procedures:
• Gastric bypass surgery creates a small pouch at the top
of the stomach. It makes a direct connection between the stomach
and a lower section of the small intestine, skipping the duodenum
entirely. Assign code 44.39 for this procedure. If gastric bypass
surgery is done laparoscopically, do not assign a code for the laparoscope
since it is considered the operative approach.
• Roux-en-Y gastric bypass creates a small stomach pouch to
restrict food intake. Then, a Y-shaped section of the small intestine
is attached to the pouch to allow food to bypass the lower stomach,
duodenum, and first portion of the jejunum. The bypass reduces the
amount of calories and nutrients the body absorbs. Roux-en-Y bypass
is assigned code 44.39. However, if the bypass is specified as a
gastric bypass with high gastrojejunostomy or short limb roux-en-Y
gastroenterostomy, then assign code 44.31.
• Biliopancreatic diversion (BPD) involves removing a portion
of the stomach but retaining the pyloric valve. The small portion
of the stomach that remains is connected directly to the ileum,
completely bypassing the duodenum and the jejunum. BPD is assigned
codes 43.7, 45.51, and 45.91. A new index entry under the main term
diversion was added to ICD-9-CM effective October 1, 2003.
• Duodenal switch, a variation of the BPD, leaves a larger
portion of the stomach intact, including the pyloric valve. It also
keeps a small part of the duodenum in the digestive pathway. Duodenal
switch is assigned codes 43.89, 45.51, and 45.91. A new index entry
under the main term diversion was added to ICD-9-CM effective October
1, 2003.
Sleeve gastrectomy/sleeve resection of the stomach
is assigned code 43.89, Other partial gastrectomy (AHA Coding Clinic
for ICD-9-CM, 2003, third quarter, pages 3-8).
Coding and sequencing for obesity are dependent
upon the physician documentation in the medical record and application
of the Official Coding Guidelines for inpatient care. Also, use
specific AHA Coding Clinic for ICD-9-CM and American
Medical Association CPT Assistant references to ensure
complete and accurate coding.
— This information was prepared by Sharon
Powell and Audrey Howard, RHIA, both of 3M Health Information Systems
(800-367-2447), a leading supplier of coding and classification
systems to nearly 4,000 healthcare providers. The company and its
representatives do not assume any responsibility for reimbursement
decisions or claims denials made by providers or payors as the result
of the misuse of this coding information.
