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A physician documents in the A/P obesity, unspecified, 278.00. However according to weight and BMI, patient is morbidly obese. Can we change this to represent this or do we have to go by what is documented by the physician?
My ICD-9 book provides the DEF: Obesity NOS (BMI between 30.0 and 39.9) Morbid obesity (BMI 40 or greater) Overweight (BMI 25- 29.9). Since it is definied in the ICD 9 book and the BMI is documented, I see no reason not to code it as the ICD 9 book defines it.
No you cannot change the providers diagnosis. The coding guidelines under general guidelines number 16, tells you that the clinician may calculate and document the BMI, but the clinical diagnosis of obesity must come from the provider and if they do not match the provider must be queried
There's a coding clinic on this (2Q2010); Deb's correct, you can't change the provider's diagnosis. You can get the BMI from a dietitian or nurse, but if they don't match, then you should query the provider for clarification.
Query the provider and most likely you will find the provider does not want to be the one who labeled a patient as "morbidly obese" even when the numbers indicate this. I review lots of records and have seen a patient with BMI of 40+ with the doctor stating "patient is slightly overweight."