Per coding clinic, the provider must provide documentation of a clinical condition to code BMI as a secondary diagnosis. Hope this helps
Please refer to Coding Clinic 4Q08, Vol # 25, Number 4, Page 191. I have copied it below for your reference.
Ask the Editor
We understand that while body mass index (BMI) code assignment may be based on documentation found in a dietitian’s note, the codes for overweight and obesity should be based on the provider’s documentation (the physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis).
Can the BMI codes (V85.x) be assigned on the basis of the dietitian’s note without a corresponding documented diagnosis of overweight, obesity or morbid obesity from the provider?
If the BMI has clinical significance for the patient encounter, the specific BMI value may be picked up from the dietitian’s documentation. The provider must provide documentation of a clinical condition, such as obesity, to justify reporting a code for the body mass index . To meet the criteria for a reportable secondary diagnosis, the BMI would need to have some bearing or relevance in turns of patient care. For reporting purpose, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:
Clinical evaluation; or
Therapeutic treatment; or
Diagnostic procedures; or
Extended length of hospital stay; or
Increased nursing care and/or monitoring
Once the provider has provided documentation of the clinical condition, such as obesity, the coder can use the dietitian’s note to assign the appropriate BMI codes from category V85.
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