Obese vs. Obesity

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8
Location
Coquille, OR
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0
Although there is many coding clinics and conversations regarding obesity, BMI, etc. I am still a little gray on the description "obese" in the physical exam.

Inpatient Chart A
MD documents in the physical exam only, "GENERAL: male moderately obese... GI: abdomen is soft, obese, ..." There is no further documentation in assessments, progress notes, or discharge summary that states "obesity" as a diagnosis. BMI is documented by RN as 36.

Inpatient Chart B
MD documents in the physical exam "She is morbidly obese"

Can obesity (or morbid obesity, in chart B) be picked up with only a description of obese in physical exam?

Thank you in advance for your response.
 

Pathos

True Blue
Messages
614
Location
Beaverton OR
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1
I am often able to pick up morbid obesity codes from the physical exam, regardless if they state "obesity" or "morbid obese". I don't think you will find any reference materials on this subject, but I see no argument against picking up such a diagnosis, unless otherwise contradicted elsewhere in the patient chart.
 
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