Obesity is a complex, chronic disease with significant health risks. Effective October 1, 2024, new ICD-10-CM codes for both adult and childhood obesity became available. These changes represent a significant shift in the way obesity is diagnosed and managed in clinical settings. These codes align with the latest recommendations from leading professional societies, such as the American Academy of Pediatrics and the American Board of Obesity Medicine, aiming to improve the accuracy of obesity diagnoses and enhance treatment options for patients of all ages.
Understanding Obesity
Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat and/or body water. Both terms mean that a person's weight is greater than what's considered healthy for his or her height. Obesity occurs over time when you eat more calories than you use. The balance between calories-in and calories-out differs for each person. Factors that might tip the balance include your genetic makeup, overeating, eating high-fat foods and not being physically active. Being obese increases your risk of diabetes, heart disease, stroke, arthritis and some cancers.
Obesity is a status with body weight that is grossly above the acceptable or desirable weight, usually due to accumulation of excess fats in the body. The standards may vary with age, sex, genetic or cultural background. Having a high amount of body fat.
New ICD-10-CM Codes for Obesity
This update comes in response to the growing recognition that the previous coding system did not adequately capture the varying degrees of obesity, leading to inconsistent reporting, treatment, and management. With these new codes, healthcare providers will now have a more precise set of tools for coding obesity based on severity, contributing to more effective patient care, improved clinical outcomes, and a reduction in stigma associated with obesity.
Prior to this update, the ICD-10-CM codes failed to fully represent the various levels of obesity severity, leading to gaps in treatment and underreporting in medical claims data. Obesity, particularly in children, is classified according to age- and gender-specific percentiles, making coding accuracy crucial for appropriate diagnosis and intervention. The new codes reflect the latest clinical guidelines, offering a more granular approach to the diagnosis of obesity, particularly in relation to its severity and associated complications.
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For pediatric patients, the above codes are accompanied by a set of new Z-codes based on age- and gender-specific BMI percentiles. These Z-codes will be used alongside the E66 codes to provide a more detailed picture of obesity severity in children and adolescents. Importantly, these new codes will replace older codes (e.g., E66.01, E66.09), ensuring that the new classification system is integrated into clinical practice moving forward.
The previous ICD-10-CM codes were limited in their ability to accurately capture the severity of obesity. By providing a more precise classification system, the new codes will enable healthcare providers to better diagnose and manage obesity. This is particularly important for pediatric patients, where the severity of obesity can vary significantly based on age and growth patterns.
Examples of ICD-10-CM Codes
- E00-E89: Endocrine, nutritional and metabolic diseases.
- E66: Overweight and obesity.
- E66.0: Obesity due to excess calories.
- E66.01: Morbid (severe) obesity due to excess calories.
- E66.09: Other obesity due to excess calories.
- E66.1: Drug-induced obesity.
- E66.2: Morbid (severe) obesity with alveolar hypoventilation.
- Z00-Z99: Factors influencing health status and contact with health services.
- Z68: BMI.
The Role of Z-Codes
Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:(a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.(b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.
Why New Codes are Necessary
Obesity is a complex, chronic disease that poses serious health risks, contributing to increased medical costs and reduced quality of life. In both adults and children, obesity has been a significant public health challenge, driving a need for more precise medical classification systems.
Obesity has been historically under-coded in healthcare claims data, which has limited the ability to fully understand the healthcare burden and associated costs of the disease. The new codes are expected to improve coding practices, enabling more accurate data collection and analysis, and facilitating research into obesity prevention and treatment. With better data, healthcare providers and policymakers will be able to develop more effective strategies for addressing the obesity epidemic.
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Obesity is a condition often associated with stigma, which can create barriers to effective treatment. The new ICD-10-CM codes aim to reduce this stigma by using clinically relevant terms that focus on severity rather than pejorative descriptors. For example, healthcare providers are encouraged to use terms like "Class III Obesity" instead of "morbid obesity due to excess calories," fostering a more supportive and respectful patient-provider relationship.
By distinguishing between different classes of obesity, the new codes will help healthcare providers tailor treatment plans to the specific needs of each patient. This individualized approach to obesity care is essential for improving health outcomes, particularly in children and adolescents who may require early and ongoing interventions to manage their weight effectively.
Ozempic and Weight Loss: Coding Considerations
Over the past year, Ozempic, Mounjaro, and Wegovy have been featured in the news and in social media as weight-loss miracle drugs. Allowing off-label use of weight-loss drugs intended for type 2 diabetes patients will impact the supply chain for the patient population with a medical need, increase your overall health plan spend, and create long-term, health care costs in patients that develop unforeseen conditions associated with off-label use.
Three weight-loss drugs are approved by the FDA (Food and Drug Administration) for persons with type 2 diabetes and obesity, and the names of the generic drug are tirzepatide, liraglutide, and semaglutide. Collectively, the brand names of these weight-loss drugs include Mounjaro, Ozempic, Wegovy, Rybelsus, Saxenda, and Victoza. Three additional weight-loss drugs approved by the FDA that are not specific to type-2 diabetes patients who are obese or overweight with weight-related medical conditions and the generic drug names are orlistat [prescription and OTC], naltrexone and bupropion [combination], and phentermine and topiramate [combination]. Collectively, the brand names of these weight-loss drugs include Qsymia, Alli, Xenical, and Contrave.
The coding information and guidance are valid at the time of publishing.
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Specific Coding Questions Addressed
- Q: Ozempic has been in the news a lot for its off-label use as a weight loss medication. If Ozempic is being used for weight loss, should code Z79.85 be reported?
- A: No. Report this code only when Ozempic is being used for diabetes.
- Clarification: Our office does complete code capture, but we are not clear if we can add Z79.85 when an obese patient is prescribed Wegovy for weight loss, but does not have diabetes. Similar, but different… All of the drugs listed above are considered to be anti-diabetic medications and are used to either treat or prevent diabetes or obesity. So, Z79.84 & Z79.85 would apply in your scenarios. I am concerned about using that code if the patient is not using the medicine for that. Especially since it could have a negative effect on the patient's insurance and premiums. Are you adding that code to patients who take metformin for PCOS? I did do some research as I have never added that code to a patient with PCOS who is on Metformin or honestly, to an obese patient who takes the drugs above for weight loss. The coding guidelines reference them in the diabetes section. I am not saying one way is right or wrong, I am just asking for clarity. Our office does complete code capture, but we are not clear if we can add Z79.85 when an obese patient is prescribed Wegovy for weight loss, but does not have diabetes. Similar, but different…
Additional Considerations for Coding
If pt overweight or morbid obese use dx E66 or E63 blocks add the BMI % weight of Z68. Then add the medication if used to help weight loss and Z71.3 Diet modification last. Ensure this is document in current record too.
Practical Steps for Healthcare Providers
As the new ICD-10-CM codes are set to go into effect in October 2024, healthcare providers should begin preparing for their implementation now.
- Update Coding Practices: Replace outdated codes with the new E66 and Z68 codes. Ensure that your Electronic Health Record (EHR) system is updated and that your billing team is familiar with the new coding practices.
- Educate Clinical Staff: Share this information with your clinical team to ensure that everyone is aware of the new codes and how to use them appropriately.
- Communicate with Patients: Use this opportunity to talk to your patients about the changes in obesity care, emphasizing the importance of using accurate, clinically relevant terms when discussing their treatment options.
Prescription Fraud and Weight Loss Drugs
In the world of âPrescription Fraud,â health plans must first determine the âSubjectâ of the investigation or review. This could be the member, the pharmacy, or the authorizing physician. There are instances where a prescription fraud investigation may involve (2) or more subjects, such as the doctor and the filling pharmacy. Determining the top authorizing physician is essential if a user identifies a pharmacy billing many weight loss prescription drug claims. This analysis could help to tell if the pharmacy and doctor have a business relationship. Furthermore, analyzing the specialty of the prescribers would also be beneficial. Obesity or weight management is often treated by gastroenterologists, clinicians within the bariatric specialty, gynecologists, or some family doctors. There has been a rise in prescription fraud cases concerned with âsteering.â An example of steering is a member using their local retail/chain pharmacy for everyday maintenance drugs but is billed a high-cost drug by a pharmacy they never use.
Wegovy, Ozempic, or Mounjaro are not considered specialty drugs. These drugs do not treat chronic critical illnesses such as cancers or multiple sclerosis (MS), they do not require special handling, nor are they considered limited distribution drugs or âLDD.â As such, most pharmacies can order these drugs through their wholesaler and dispense them to the patient.
Fraud Scope Queries
Codoxo created three Fraud Scope queries to assist their health plan partners with collecting weight loss drug prescription intelligence by Brand Name. Navigate to Query and select Library from the drop-down menu. Click on the Fraud Scope query you want to review.
- Prescriber Analysis: After the results are published, click Show Chart, and build the following charts as a starting point for analyzing prescribers. Further analysis within the Prescribing Aggregates table is available when users apply Primary Sort, descending on the Utilization Percent Difference column, which identifies the prescribers with the highest utilization compared to their prescribing peers.
- Filling Pharmacy Analysis: After the results are published, click Show Chart, and build the following charts as a starting point for analyzing filling pharmacies. Further analysis within the Filling Pharmacy Aggregates table is available when users apply Primary Sort, descending on the Utilization Percent Difference column, which identifies the filling pharmacies with the highest utilization compared to their filling peers.
- Patient Analysis: After the results are published, click Show Chart, and build the following charts as a starting point for analyzing prescribers and patients of interest. Additional Show Chart options are available based on the analysis needs for the health plan.
When a Patient ID displays prescriptions for more than one weight loss drug, especially those with mixed prerequisite conditions, the user should click on the Patient ID to navigate to the Patient, Lines page. Click Show Chart, choose Diagnosis Code as Variable 1 and click Plot Chart. Patients with prescriptions for Mounjaro, Ozempic, Wegovy, Rybelsus, Saxenda, or Victoza should display a type-2 diabetes diagnosis code and at least one obesity diagnosis code in their medical history. If type-2 diabetes codes are absent, identify the prescribing provider[s] in the Prescriptions sub-menu for additional review. Patients with prescriptions for Qsymia, Alli, Xenical, or Contrave should display at least obesity and/or BMI diagnosis code from the range in Table 2 in their medical history. If those codes are absent, identify the prescribing provider[s] in the Prescriptions sub-menu for additional review.
Discogenic Back Pain and DDD
If the provider documents axial or discogenic low back pain (LBP) or LBP due to DDD, assign code M51.360 or M51.362. The current indexing and guidelines do not support linking LBP to DDD without physician documentation of a cause-and-effect relationship. This is especially true in patients with multiple back conditions who could also have other causes of LBP. This is an opportunity for CDI to get involved to ensure proper reporting of the condition.
Physicians utilize a variety of diagnostic labels which lack granularity with regard to lumbar degenerative disc disease (DDD) associated with either midline axial or sclerotomal, non- radicular/non-sciatic referred leg pain. Pain may present in the low back, or may be referred to the lower extremity, or both as a result of lumbar discogenic disease. In addition, absence of pain is generally a sign that the degenerative disc disease is non-noxious. Lumbar disc degeneration also is not a definitive diagnosis as it only represents at most a morphologic sub-grade of disc degeneration by the most widely known T2-based Pfirrmann grading scoring tool available for MRI survey interpretation of the lumbar spine.
MRI has provided a paradigm shift in how lumbar spine pathology is managed; the diagnosis of DDD predates MRI and was originally based on X-ray. Treatment expectations have evolved with our understanding of provocative discography and MRI. Restorative/regenerative treatment measures address dark discs, Pfirrman grades 3-7 out of 8 grades.
Lumbar disc degeneration may, however, advance further via atraumatic or traumatic mechanisms from fissuring or bulging to a displaced disc herniation and/or stenosis. Later treatment options for lumbar disc herniation and/or stenosis include surgical decompression to address herniation-induced dermatomal radiculopathy/sciatica and stenosis-induced myelopathy.
Back pain location can be described by region. Expansion of coding for the purposes of this proposal are limited to the lumbar region as MRI Pfirrmann grades are confined to the lumbar spine only and thus major advances in spine care have mostly targeted treatment in the lumbar spine. Sciatica has come to mean dermatomal or radicular leg pain and may be differentiated from nociceptive/referred (sclerotomal)/non-radicular pain by exam. That is to say that radiculopathy is diagnosed clinically by a positive straight leg raise, Lasegueâs sign, crossed Lasegueâs sign, positive bowstring, positive femoral stretch test and motor/sensory/reflex change.
Chronic low back pain (CLBP) or lumbago has 6 sources including: (1) discogenic; (2) facetogenic; (3) neurocompressive including herniation and stenosis; (4) sacro-iliac; (5) vertebrogenic; and (6) psychogenic. The predominant source of CLBP is discogenic low back pain (DLBP). Discogenic back pain associated with DDD can be multifactorial and difficult to treat. The type of pain present and whether it is primarily LBP or leg pain or both is an important component of the clinical assessment. Treatments for discogenic back pain have ranged from anti-inflammatory medications to invasive procedures including spinal fusion and spinal arthroplasty.
Clarification on Discogenic Back Pain Coding
- Q: With these new codes we originally thought âdiscogenicâ back pain had to be documented as such but seeing that they add the word âaxialâ does this constitute simply âlow back pain not further specifiedâ? Axial pain is a common type of low back pain and is usually non-specific. It is confusing because the wording for M51.369-states without mention of lumbar back pain and does not state âdiscogenicâ or âaxialâ. So if a patient has DDD of the lumbar region with low back pain should we be coding M51.360 even though the documentation does not specify discogenic or axial low back pain. It would also feel weird to code M51.369 when patient does have low back pain. Can you please help us understand?
- A: If the provider documents axial or discogenic low back pain (LBP) or LBP due to DDD, assign code M51.360 or M51.362. The current indexing and guidelines do not support linking LBP to DDD without physician documentation of a cause-and-effect relationship. This is especially true in patients with multiple back conditions who could also have other causes of LBP. This is an opportunity for CDI to get involved to ensure proper reporting of the condition.
Metabolic Syndrome
A cluster of metabolic risk factors for cardiovascular diseases and type 2 diabetes mellitus. The major components of metabolic syndrome x include excess abdominal fat; atherogenic dyslipidemia; hypertension; hyperglycemia; insulin resistance; a proinflammatory state; and a prothrombotic (thrombosis) state. A collection of metabolic risk factors in one individual. The root causes of metabolic syndrome are overweight / obesity, physical inactivity, and genetic factors. Various risk factors have been included in metabolic syndrome. A condition is marked by extra fat around the abdomen, high levels of blood glucose (sugar) when not eating, high levels of triglycerides (a type of fat) in the blood, low levels of high-density lipoproteins (a type of protein that carries fats) in the blood, and high blood pressure. A term referring to a combination of medical conditions that, when present, increase the risk of heart attack, stroke, and diabetes mellitus. Metabolic syndrome is a group of conditions that put you at risk for heart disease and diabetes. These conditions are high blood pressure high blood sugar levels high levels of triglycerides, a type of fat, in your blood low levels of hdl, the good cholesterol, in your blood too much fat around your waistnot all doctors agree on the definition or cause of metabolic syndrome. The cause might be insulin resistance. Insulin is a hormone your body produces to help you turn sugar from food into energy for your body.