Coding Clinic – 4th Quarter 2018- Key Highlights

Coding Clinic 4th Quarter 2018 had an extensive question and answer section seeking to clear up any confusion regarding BMI coding. Much of the information was a reiteration of what has already been published in prior Coding Clinic issues and the Official Guidelines for Coding and Reporting. Below is a summary of the key points and other highlights from this issue including lacunar infarctions, gangrene and perforation of gallbladder, extracorporeal membrane oxygenation (ECMO), and spinal fusion.

Body Mass Index (BMI) Coding

  • BMI codes can only be assigned when a corresponding clinical condition such as overweight, obesity or morbid obesity underweight, malnutrition, anorexia nervosa or other eating disorders, cachexia, and abnormal weight loss/gain is documented
  • If the linkage between the BMI and a clinical condition is not clearly documented, query the provider for clarification
  • Obesity and morbid obesity are always clinically significant and reportable when documented by the provider
  • If morbid obesity is documented, assign E66.01, morbid obesity due to excess calories, even if the patient’s BMI is below 40
    • Per the Official Coding Guidelines: The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.
    • The provider’s statement that the patient has a particular condition is sufficient.
    • Code assignment is not based on clinical criteria used by the provider to establish the diagnosis
  • Documentation of “overweight” with BMI can only be coded if the provider documents the clinical significance of being overweight (i.e. must meet the definition of a reportable secondary diagnosis)
  • Reportable secondary diagnosis must meet one of following criteria:
    • clinical evaluation
    • therapeutic treatment
    • diagnostic procedure(s)
    • extended length of hospital stay
    • increased nursing care and/or monitoring
  • Examples of documentation that may meet criteria for reportable secondary diagnoses
    • Documentation of weight loss, a special diet, a Hoyer lift, nutrition involved
    • Loss or gain of weight, and advice to improve the situation revolving around weight
    • General weight loss/lifestyle modification strategies discussed (elicit support from others; identify saboteurs; non-food rewards, etc.),
    • Informal exercise measures discussed, e.g., taking stairs instead of elevator.
  • Per the Official Coding Guidelines, do not assign BMI codes during pregnancy
    • Only assign O99.214, Obesity complicating childbirth with the specific obesity code from category E66-, Overweight and obesity


  • Extracorporeal Membrane Oxygenation, Continuous (5A15223), has been deleted from ICD-10-PCS and has been replaced with 3 new codes:
    • 5A1522F – Extracorporeal oxygenation, membrane, central
    • 5A1522G – Extracorporeal oxygenation, membrane, peripheral veno-arterial (VA)
    • 5A1522H – Extracorporeal oxygenation, membrane, peripheral veno-venous (VV)
  • Per Coding clinic, in the past, central ECMO was more commonly used; however, peripheral ECMO is more common now. For central ECMO, assign code 5A1522F, Extracorporeal oxygenation, membrane, central.
  • Assigning 5A1522G (ECMO-VA) or 5A1522H (ECMO-VV) with CHF as the PDX act as an MCC resulting in DRG 291 Heart Failure & Shock or Peripheral ECMO

Joint Fusion Device Value

  • Coders can no longer assign codes for joint fusions without knowing the type of device used
  • The device value “Z, No device” was deleted from tables 0RG – Fusion of Upper Joints and 0SG – Fusion of Lower Joints
  • Per Coding Clinic, this results in the deletion of 213 codes. The codes were clinically invalid because a fusion procedure always requires some type of device (for example, instrumentation with bone graft or bone graft alone) to facilitate the fusion of the joints
  • If the documentation is unclear about the device used to accomplish the fusion, then these cases must be held and queried for clarification

Lucunar Infarction

  • Lucunar infarctions finally have their own code: I63.81 – Other cerebral infarction due to occlusion or stenosis of small artery
  • Per Coding Clinic, lacunar infarcts are small cerebral infarctions in the deep cerebral white matter, basal ganglia or pons
  • They are presumed to result from the occlusion of a single small perforating artery supplying the subcortical areas of the brain
  • Lacunar infarcts account for approximately one-fourth of all ischemic strokes

Gangrene and Perforation of Gallbladder in Cholecystitis

  • New code: K82.A1 – Gangrene of gallbladder in cholecystitis (CC)
    • Gangrene of gallbladder was previously a non-essential modifier/included with K81.0 – Acute cholecystitis
    • Gangrene of gallbladder in cholecystitis now has its own code which is a (CC)
  • New Code: K82.A2 – Perforation of gallbladder in cholecystitis (CC)
    • Perforation of gallbladder was previously captured with K82.2 – Perforation of gallbladder, which was an (MCC)
  • When coding cholecystitis cases, make sure to assign the correct codes using the latest codeset because of the DRG implications


  1. AHA Coding Clinic – 4th Quarter 2018 effective October 8, 2018

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