Health Information Management

Q&A: Documentation for body mass index

CDI Strategies, May 8, 2014

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Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician like the dietitian or nurse? I thought that we could use ancillary documentation for clinical indicators supporting our physician query but that the treating physician needed to document the BMI. Can you help clarify this for me?

A: Documentation of the BMI can be taken from either the physician or a nonphysician (such as a dietitian or nurse). It is usually taken from a nurse or dietician’s documentation, as this has become a standard piece of their admission assessments. (Nursing staff routinely will weigh the patient during admission.)

The important piece to remember is that the physician must first document the clinical condition (such as obesity) to allow us to then code the BMI. For example, a BMI of greater than 40 will provide a CC. But we cannot not code the BMI of greater than 40 without first having the documentation of the obesity from the physician. Obesity alone will not provide a CC.

Editor’s Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.This article was originally published on the ACDIS Blog.



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