Let us look into Obesity BMI value table, Obesity ICD 10 codes and guidelines with examples.
We all are very much aware of the term obesity which is increased amount of fat cells in body. This may be due to physical inactivity, lack of exercise, eating habits, hereditary or stress. Number of obese patients are increasing day by day in the world. Obesity needs to be controlled as it leads to many serious medical conditions like diabetes, hypertension and heart disease. It is even noticed that an obese person show severe symptoms when affected with COVID-19.
When coding for obesity it is important to know how a person is considered as obese. This is decided based on BMI (body mass index) value which is calculated with the person’s height and weight.
Below table indicates the interpretation based on BMI value
|< 16.0||Severe malnutrition|
|16.1 to 16.9||Moderate malnutrition|
|17.0 to 18.4||Mild malnutrition|
|18.5 to 24.9||Normal|
|25.0 to 29.9||Overweight|
|30.0 to 39.9||Obese|
During a health check up physician will take medical history and do physical exam including calculation of BMI. Depends on your health, there may be blood tests done to determine cholesterol and glucose level. Calorie controlled diet counselling is a part of obese patient’s treatment.
Obesity ICD 10 codes and guidelines
Obesity ICD 10 and related codes are found in various chapters. Underweight and abnormal weight gain codes are found in chapter 18 – signs, symptoms and abnormal clinical and laboratory findings, code range R00-R99. Chapter 4 includes obesity – endocrine, nutritional and metabolic diseases, code range E00-E89. Chapter 21 includes BMI codes – factors influencing health status and contact with health services, code range Z00-Z99
BMI for Adult (20 years and above) – Z68.0 to Z68.45
BMI for pediatric (2 to 19 years old) – Z68.51 to Z68.54
- BMI can be coded even if it is documented by dietitian. But at the same time obesity or overweight should be documented by the treating provider.
- BMI codes (Z68) should only be coded when there is a diagnosis such as obesity, overweight, underweight etc.
- BMI codes (Z68) can not be coded as primary.
Other codes for obesity and weight are given below:
R63.5 – Abnormal weight gain
R63.6 – Underweight
Obesity ICD 10 Codes Example 1
70 year old female is here today for annual wellness exam. She is known to have COPD, hyperlipidemia and diabetes. She is wheezing from time to time. Her diabetes is controlled with insulin and cholesterol is stable with crestor 10 mg daily. She gets hypoglycemic episodes sometimes. Her vitals are normal. BMI measures today as 56.2 kg/m2. Physical exam documents morbidly obese, ambulate without assistance, decreased breath sounds, no swelling or tenderness on skin and no musculoskeletal abnormalities. Blood lab tests and chest X-ray was done. Counselling provided on calorie diet and reduced insulin dosage to manage hypoglycemia.
This case would be coded as:
J44.9 – COPD
E11.9 – DM
E78.5 – Hyperlipidemia
E66.01 – Morbid Obesity
Z68.43 – BMI
Z79.4 – Insulin use
Note : Obesity should be coded from physical exam along with current BMI value.
Obesity ICD 10 Codes Example 2
Maria is a 52 year old woman who comes to clinic for extreme tiredness from past few days. She was diagnosed with diabetes 2 years back and started on Glyburide 2.5 mg daily morning. She is not taking this medicine now due to dizziness. She does not check glucose at home regularly. She also has high cholesterol maintained with Lipitor. She is an obese female with BMI of 36.2kg/m2 and fasting glucose of 166 mg/dL. Her lung exam showed no abnormalities, heart exam showed regular rate and rhythm without murmur. Lipid Panel was also done which showed triglycerides of 177 mg/dl. Based on today’s findings assessment was made as follows:
Diabetes poorly controlled, hypercholesterolemia, obesity.
This case would be coded as:
E11.65 – DM poorly controlled
E78.00 – Hypercholesterolemia
E66.9 – Obesity
Z68.36 – BMI