Wiki Coding for Obesity

[Amy Pritchett]

Hello All!!
Can someone please point me in the direction of an "Official Guideline" for the coding of obesity, moderate obesity or severe obesity? I have researched and found that under this situation if the BMI is listed in the History and Physical then, the physician does not have to document the obesity to be able to document whether moderate or severe. I have noticed in the research that you can pick up the BMI and then code the ICD-9-CM code that corresponds.
Any suggestions would be helpful!

 

[mitchellde]

The coder cannot code obesity based only on the BMI, the guidelines state that the obesity level ( obese , morbid obesity, overweight ) must be documented by the provider. The BMI may be recorded by any qualified office staff. Here is the guideline:

Documentation for BMI and Pressure Ulcer Stages
For the Body Mass Index (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), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often documents 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.