Health Information Management

New guidance for coding BMI and pressure ulcers

Briefings on Coding Compliance Strategies, March 1, 2009

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New guidance, which appears in the updated ICD-9-CM Official Guidelines for Coding and Reporting and Coding Clinic, fourth quarter 2008, took effect October 1, 2008. It gives coders the ability to code the stage, not the site, of a pressure ulcer based on documentation from a nurse or other clinician.

The same Coding Clinic reminds coders that they can code a patient’s BMI using documentation from a dieti¬tian when the BMI has clinical significance to the patient encounter. (Guidance on this topic first appeared in Cod¬ing Clinic in 2005.)

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