Health Information Management

Q&A: Obtaining documentation for patients' body mass index

CDI Strategies, May 9, 2013

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Q: I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians, it can be coded if the physician documents the clinical significance (i.e., morbid obesity).  However, if the BMI is documented by a patient care tech or nursing ward secretary in the medical record, would the physician need to be queried for agreement with the BMI value as documented by these non-licensed employees?

A: For BMI and pressure ulcer stage codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). The key word here is “clinicians.” Their documentation is typically allowed because they are involved in the care of the patient (e.g., a dietitian often documents the BMI, and nurses often document the pressure ulcer stages).
 
However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.
 
The BMI and pressure ulcer stage codes should only be reported as secondary diagnoses. As with all other secondary diagnosis codes, the BMI and pressure ulcer stage codes should only be assigned when they meet the definition of a reportable additional diagnosis.
 
To use documentation from a patient care technician, you would need to establish a policy outlining their responsibilities (and training) to do so.
 
Documentation of BMI by a ward secretary would be a risk in my opinion, since these individuals do not typically provide patient care and cannot be considered a clinician.
 
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.



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