Wiki Obese vs. Obesity

[jmddwilson]

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]

Based on your information, I would pick up E66.9, and Z68.36 for chart A, and E66.01 for chart B. Obese is considered the same as obesity in my opus.

Here is an article (yes I know it's from WebMD, but the wording is still relevant) which uses Obese and Obesity interchangeably.
https://www.webmd.com/diet/obesity/features/am-i-obese#1

 

[jmddwilson]

Since obese is used as an adjective in physical exam, we can translate that to a diagnosis?

 

[Pathos]

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.