Topic: Obesity severity/specificity in a pediatric case
H&P: 8 y/o otherwise healthy male presents with fever, poor intake, and rash that progressively worsened over the last 7 days. Patient had throat pain and fever a week ago and was given a 10-day course of amoxicillin. Following the initiation of the amoxicillin, patient developed a rash which started on the chest and then spread to face and groin.
PMH: No significant past medical or surgical history
Home Medications: Amoxicillin 250mg day 7 of 10, Ondansetron 4mg PRN, Tylenol and Ibuprofen PRN.
Vitals: BP 102/55, HR 101, temperature 37.4 C, RR 19, weight 40kg, height 121cm, SpO2 100%
PE: Well-nourished 8 y/o male with fever, diffuse rash, lips mildly swollen with no cracking or fissuring. Shotty lymph nodes palpated throughout neck. Multiple plaques 1-2cm in diameter with coalescing lesions on upper back, upper neck, face, and groin regions. 12-point system review is otherwise negative.
Labs: WBC 9.3; RBC 5.11; Hgb 13.3; Hct 37; Platelets 180; Glucose 82; Sodium135; Potassium 4.1; Bilirubin 0.32; Creatinine 0.61; CRP 4.3 mg/dL; Procalcitonin 0.16 ng/mL
Nutrition Assessment: Weight 40kg, Height 121cm, BMI 27.3. Patient with severe obesity; provided parents and child with dietary counseling.
Assessment/Plan: 8 y/o male presents with rash. Previous negative Monospot test, but positive EBV serology with IgM, IgG antibodies (titers IgM > IgG), and diffuse neck lymphadenopathy consistent with acute EBV infection. Admitted due to initial concern for MIS-C and IV fluids for rehydration.
Discharge Summary: Labs indicative of inflammation but did not meet MIS-C criteria. EBV titers indicate acute EBV infection. Diffuse rash most likely amoxicillin induced. Dietary counseling completed for weight management.
Discharge Medication: Diphenhydramine 12.5mg every 6 hrs PRN, Ibuprofen 100 mg every 6 hrs PRN
Question: Are there query opportunities based on the scenario stated above?
Discussion: 8 y/o patient on day 7 of 10-day course of amoxicillin presents with worsening rash, fever, and lab confirmed acute EBV infection. Nutrition assessment indicates a BMI of 27.3, placing the BMI-for-age at the 99th percentile (136% of the 95th percentile) for boys aged 8 years, meeting the criteria for severe obesity.
Diagnostic Criteria for Severe Obesity: For children over the age of 2 years, definitions for overweight and obesity are based on the Body Mass Index (BMI).1 For children, BMI varies not only with weight but also varies with age and is age- and sex-specific and is often referred to as BMI-for-age.1 Using the BMI, overweight and obesity for Children and Adolescents is defined as follows: Overweight: BMI >85th percentile and <95th percentile, Obesity: BMI >95th, Severe (morbid) obesity: is either ≥120% of the 95th percentile curve, or BMI ≥35 kg/m2 (whichever is lower).1,2
Treatment: IV fluids, Tylenol and Ibuprofen PRN pain/fever, Atarax PRN itching, Dietary consult for counseling and surveillance for severe obesity
UASI Recommends: Query for severity and specificity of obesity in pediatric patients when nutrition assessment meets the CDC’s definition for childhood obesity.
Documentation without Clarification:
- Principal Diagnosis: Generalized skin eruption due to drugs and medicaments taken internally (L27.0)
- Secondary Diagnosis: Gammaherpesviral mononucleosis without complication (B27.00); Dehydration (E860); Adverse effect of penicillin, initial encounter (T36.0X5A).
- Working APR DRG: 385- Other skin, subcutaneous tissue & breast disorders RW: 0.3771 ***SOI/ROM: 1/1
Documentation with Clarification:
- Principal Diagnosis: Generalized skin eruption due to drugs and medicaments taken internally (L27.0)
- Secondary Diagnosis: Gammaherpesviral mononucleosis without complication(B27.00); Dehydration (E86.0); Adverse effect of penicillin, initial encounter (T36.0X5A); Severe obesity due to excess calories (E66.01); BMI pediatric, greater than or equal to 95th percentile for age (Z68.54); Dietary counselling and surveillance (Z713).
- Working APR DRG: 385- Other skin, subcutaneous tissue & breast disorders RW: 0.5252 ***SOI/ROM: 2/1
***APR-DRG V35 (FY2018)
CDI Educational Tips:
Coding considerations:
- To accurately capture the severity of illness of pediatric patients, it is recommended the CDS do a comprehensive review of the medical record to include a nutritional assessment of pediatric patients and query the provider for specificity and severity of obesity when the nutrition screen meets the CDC’s definition for childhood obesity.
- U.S. Preventive Services Task Force (USPSTF) recommends clinicians screen for obesity in children and adolescents >6 years, and offer comprehensive interventions to promote ideal weight status3. The Official Guidelines for Coding and Reporting, Section I.B.14, requires that associated diagnoses such as overweight or obesity be documented by the patient’s provider4. Consistent assessment of weight status should be part of clinical care and CDI review. CDS should consistently review and plot BMI values on CDC’s gender-specific BMI-for-age charts and assist providers in implementing evidence-based recommendations to document obesity in children.
Thank you to Evangelin Beedilla Daniel from Valley Children’s for your contribution to this month’s CDI Scenario.
References:
- Centers for Disease Control and Prevention. (2018). Defining Childhood Obesity. Retrieved on 11/11/2020 from https://www.cdc.gov/obesity/childhood/defining.html
- Klish, W.J., Skelton, J. A. (2020). Definition, epidemiology, and etiology of obesity in children and adolescents. UpToDate. Retrieval on 11/11/2020 from https://www.uptodate.com/contents/definition-epidemiology-and-etiology-of-obesity-in-children-and-adolescents?search=obesity%20in%20children&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
- USPSTF. (2017, July). Screening for Obesity in Children and Adolescents: Clinical Summary. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-children-and-adolescents-screening
- CDC. (2020). ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 (October 1, 2020 – September 30, 2021). Section I.B.14. Retrieved from https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2021.pdf
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.