March 2, 2020

What's wrong with how we diagnose obesity? Blame ICD-10, according to these researchers.

Daily Briefing

    Obesity is a complex condition that is influenced by a variety of factors, yet clinicians often struggle to properly treat obesity because the diagnostic codes they rely on are too narrowly defined, according to a paper published in Obesity last week, Kat Eschner reports for Popular Science

    Infographic: The right route to avoid pitfalls of chronic disease management

    The problem with diagnostic codes for obesity

    The latest CDC data show about 42% of U.S. adults have obesity, and medical costs related to obesity reach hundreds of millions of dollars annually.

    But despite the prevalence of the condition and the costs associated with it, W. Timothy Garvey, a professor of medicine at University of Alabama at Birmingham's Department of Nutrition Sciences, and Jeffrey Mechanick, an endocrinologist and professor at Mount Sinai University, note that few patients have access to evidence-based therapies.

    The reason, Garvey and Mechanick argue, is in part because clinicians must rely on the over-simplified diagnostic code, E66.0, associated with the condition.

    This "key ICD-10 code for obesity" is defined as "obesity due to excess calories," which the authors write "is not medically meaningful and does not reflect obesity pathogenesis." For instance, Eschner reports that the code does not take into account the "huge variety of factors, from physical and mental health to genetics and upbringing, [that] all contribute to" obesity.

    In fact, the authors write the code's reliance on "excess calories" perpetuates a negative perception that obesity is a choice for patients.

    All of these "inadequacies contribute to a lack of access for patients to evidence‐based therapies and a lack of appreciation of obesity as a chronic disease," Garvey and Mechanick write.

    In addition, they note that the current code can present hurdles to reimbursement.

    Rekha Kumar, the medical director of the American Board of Obesity Medicine, said, "At this time, coding visits with the diagnosis 'obesity' or anything that has the word obesity in it leads to inconsistent [insurer] reimbursement or none at all."

    A better way of coding obesity?

    The solution, according to Garvey and Mechanick, is a broader classification system for coding obesity care.

    In the paper, they propose using an ICD coding system based on ABCD, or "adiposity-based chronic disease." The coding system relies on four domains: "A codes reflect pathophysiology, B codes indicate BMI classification, C codes specify specific biomechanical and cardiovascular complications remediable by weight loss, and D codes indicate the degree of the severity of complications," they write. The system also has flexibility for supplemental codes to reflect a personalized therapeutic care plan.

    The coding system isn't new, Eschner reports. In fact, it's been supported by American Association of Clinical Endocrinologists and other medical groups. However, it has not been widely adopted.

    In the paper, Garvey and Mechanick argue that the new codes would encourage providers to recommend patients do more than just lose weight because the codes would allow clinicians to bill for the time they've spent trying to figure out what underlying conditions are contributing to a patient's obesity, including depression, food insecurity, and injuries preventing a patient from being active.

    Discussion

    However, some observers are unsure whether the codes would have an immediate impact on obesity care.

    Kumar said ABCD "might encompass more aspects of the disease than just 'obesity,' but the key will be whether this terminology actually changes practice and reimbursement."

    Arya Sharma, the scientific director of Obesity Canada, said he believes it would take a long time before ABCD would go into effect. The latest edition of ICD codes are about to be released, which means ABCD would need to be included in the ICD update after that, meaning making the update would be "a very slow and a very involved process."

    That said, observers agree that codes for obesity care need to be updated. Sharma said, "There's no doubt that the current ICD codes are not helpful" (Eschner, Popular Science, 2/25; Garvey/Mechanick, Obesity, 2/24).

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