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November 27, 2006

Coding for Eating Disorders
For The Record
Vol. 18 No. 24 P. 37

Eating disorders are characterized by a preoccupation with weight that results in severe disturbances in eating behaviors. The three main types of eating disorders include anorexia nervosa, bulimia nervosa, and binge eating. Other variations of eating disorders include purging without binging, chewing and spitting without purging, and anorexic behavior with less severe weight loss.

Anorexia Nervosa
Anorexia nervosa (AHA Coding Clinic for ICD-9-CM code 307.1) is essentially self-starvation. The person severely limits food intake and refuses to maintain a minimally normal body weight. Because of inadequate caloric intake or excessive energy expenditure, weight loss occurs. The person’s body weight may be 15% or more below normal body weight. The person has an intense fear of gaining weight and he or she has a distorted body image.

Signs and symptoms of anorexia nervosa include the following:

• restricts foods or types of food;

• induces weight loss by vomiting, abuse of laxatives, use of diuretics or enemas, or excessive exercise;

• intense fear of gaining weight;

• sees body as overweight in spite of being underweight;

• abnormal menstrual cycle in females;

• secrecy about food and denial of an eating problem;

• fatigue;

• depression;

• irregular heart rate;

• lightheadedness;

• anemia;

• brittle hair and nails; and

• skeletal muscle atrophy.

Malnutrition commonly occurs in patients with anorexia nervosa. When a patient is admitted with malnutrition and anorexia nervosa, sequence code 307.1 as the principal diagnosis with an additional code for the malnutrition as a secondary diagnosis (AHA Coding Clinic for ICD-9-CM, 2006, second quarter, page 12). The code for malnutrition will identify the specific type and severity of malnutrition. This advice supersedes advice previously published in AHA Coding Clinic for ICD-9-CM, 1989, fourth quarter, page 11.

Bulimia Nervosa
Bulimia nervosa (307.51), which is more common than anorexia nervosa, involves the person eating large amounts of food in a short period of time (binging) followed by purging the food or reversing the expected weight gain. Binging episodes occur at least two times per week for several months or longer. Bulimia nervosa may also be documented as overeating of nonorganic disorder or binge-purge syndrome.

Signs and symptoms of bulimia nervosa include the following:

• eating more food in a binge episode than normal;

• purging after eating—not all people purge by inducing vomiting. Purging may include abuse of laxatives, diuretics, or enemas; excessive exercise; or fasting;

• feelings of loss of control during binge;

• feelings of shame, guilt, and intense fear of gaining weight after binging episode;

• unhealthy focus on body shape and weight;

• dehydration;

• fatigue;

• weakness;

• depression;

• irritability;

• dry, yellow skin;

• damaged teeth and gums from gastric acid;

• swollen cheeks; and

• irregular heart rate.

Binge Eating Disorder
A binge eating disorder is characterized by frequent episodes of overeating without purging. The person eats a large amount of food in a short period of time and feels a loss of control and is not able to stop eating. After binging, the person feels overwhelmed by guilt, embarrassment, and distress.

Signs and symptoms of binge eating disorder include the following:

• episodes of compulsive overeating not followed by purging;

• steady weight gain;

• eating when not hungry or until uncomfortably full;

• eating alone;

• fatigue;

• joint pain;

• gallbladder disease;

• hypertension; and

• hypercholesterolemia.

Bulimia (overeating) without a specified cause is assigned to code 783.6. However, if the bulimia is of nonorganic origin, assign code 307.51. Bulimia with obesity is assigned to the appropriate obesity code (278.00-278.01).

Diagnosis
A physician can diagnose eating disorders based on symptoms, a physical exam, medical history, and eating habits. The physician may also order the following tests to assess any associated complications:

• complete blood count to determine whether the patient has anemia;

• electrocardiogram to show whether the patient has irregular heart rhythms;

• chest x-ray to detect damaged heart muscles;

• computed tomography scan to determine whether there is damage to brain or digestive tract; and

• bone density test.

The physician may also perform a body mass index in possible anorexic cases to determine whether the patient is underweight.

Treatment
In all types of eating disorder cases, treatment involves the following:

• nutrition education;

• psychotherapy;

• family counseling; and

• medications to assist with depression and anxiety.

In anorexia nervosa, the patient may need to be hospitalized to treat dehydration, malnutrition, and electrolyte disorders. The patient needs to gradually restore normal body weight and eating habits.

Coding and sequencing for eating disorders are dependent on 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 Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 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. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

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