An obese woman, who is 40 weeks gestation, had a normal delivery of a healthy infant. The provider noted “Obesity” in his final diagnostic statement. There is a note in the Tabular List instructing, “Use additional code to identify the type of obesity (E66.-)” under code O99.214, Obesity complicating childbirth. Since the type of obesity is not specified, would it be appropriate to only assign code O99.214, Obesity complicating childbirth, since code E66.9, Obesity, unspecified, does not describe a type of obesity?
Facilities may develop internal facility-specific coding policies, stipulating whether to report “unspecified” codes as additional codes, when more specific information is not documented and the unspecified code does not add any useful information. Any internal facility-specific coding policies developed must be applied consistently to all health records coded.
For example, code O99.214, Obesity complicating childbirth, fully captures the diagnostic statement. Therefore, code E66.9, Obesity, unspecified, would not be needed as an additional code assignment, because “unspecified” is not a type of obesity and code E66.9 does not provide any additional information.