Physician Practice

Diagnosis coding for obesity and BMI when noted in the clinical record

Physician Practice Insider, June 28, 2016

By utilizing the information documented in the record, coders can report the BMI from a dietitian's note or from the physician’s documentation. However, if the numeric BMI falls into the “class” status, we can report and code this as a Class I, II, or III obesity state. The obesity documentation still has to be clearly defined within the medical record. With that, there should be a correlation from the physician to support the obesity code assignment, and how that is currently impacting the patients’ current care and ongoing plan.

The next coding challenge to coding an obesity diagnosis is the notation of the word “morbid” obesity. As we know from the NIH, the definition of such is defined, yet many physicians note in the record the words “patient is morbidly obese” but do not include any further information or documentation for the coder to adequately code the obesity diagnosis correctly for that particular patient.

A patient may not have all the criteria for being “morbidly obese” according to the NIH guideline, however, a physician may document that the patient is “morbidly obese” in the medical record. If the documentation of an obesity diagnosis is a pertinent part of that patient’s care or reason for his or her medical encounter, the coder is obligated to record the diagnosis accurately and may need to query the provider and ask for clarification or additional information to clearly support the “morbidly obese” diagnosis.

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