BMI documentation

twoodstwoods
edited May 2016 in CDI Talk Archive
We are a small hospital with only one dietician, Here is my dilemma..............Everything read says BMI documented by dietician in order to code with MD stating Morbid Obesity (not mentioning the BMI). When our dietician is out, is there anyone else who can document this so we do not have to hold charts for billing and enter a late entry???? This may be basic but I am stumped and new to CDI, so I ask . tytw

Theresa Woods, MSN, RN
Clinical Documentation Improvement Specialist
Jennings American Legion Hospital
1634 Elton Road
Jennings, LA 70546
Phone: 337-616-7297
Fax: 337-616-7096
twoods@jalh.com

Comments

  • digardskdigardsk
    edited May 2016
    I think you could also ask the physician to document the specific BMI
    along with the corresponding dx/condition. However, I would first be
    sure that the BMI as calculated by a non-dietician is correct (without
    frank error), and is not unduly influenced by things like fluid
    balance.

    Kim
  • robert.hodges2robert.hodges2
    edited May 2016
    I've been told by my coders here that the provider has to document not
    only the "morbid obesity" but also the BMI for them to code it. I know
    it can't be nursing. The scary part here is that our system
    automatically calculates BMI on all patients. It's just that the
    providers won't document it.


    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov


    "Anyone who has never made a mistake has never tried anything new."
    -Albert Einstein
  • jolene.filejolene.file
    As I understand, the physician or the dietician can document BMI.
  • susankleinsusanklein
    edited May 2016
    Nursing can document height & weight/BMI calculation.

    Susan A. Klein, BSN, RN, C-CDI
    Saint Peter's University Hospital
    Director, Clinical Documentation Mgt
    office: 732-339-7613
    fax: 732-745-5944 (specify room B175)
    pager: 732-651-4359
  • digardskdigardsk
    edited May 2016
    Coding Clinic 4Q08:

    Question:
    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?
    Answer:
    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
  • sharon.cooper@owensborohealth.orgsharon.cooper@owensborohealth.org
    edited May 2016
    We, as well, accept documentation of the BMI from the Nurses. Nurses are clinicians who are not the patient's provider.


    B. General Coding Guidelines; p12-13
    ICD-9-CM Official Guidelines for Coding and Reporting (effective 10/1/09)

    16. 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).


    Sharon Cooper, RN-BC, CCDS

    Owensboro Medical Health System
    Sharon Cooper, RN-BC, CCDS
    Manager Clinical Documentation
    811 E. Parrish Avenue
    Owensboro, KY 42303
    (270) 688-1277 Office
    (270) 688-2737 Fax
  • arobinsoarobinso
    edited May 2016
    Yes, that is what we understand and the coders sometimes retrieve BMI from nursing notes. After Robert's post I have searched coding clinic I do not see anything regarding BMI documentation from nursing as not being correct. Someone please correct me if I am wrong and where can I reference??

    Mandi Robinson, RN, BS, CPC
    Clinical Documentation Specialist
    Trover Health System
    270-326-4982
    arobinso@trover.org
    "Excellent Care, Every Time"
  • twoodstwoods
    edited May 2016
    I am with you mandi, I can not find where a nurse CAN NOT document the BMI.

    Theresa Woods, MSN, RN
    Clinical Documentation Improvement Specialist
    Jennings American Legion Hospital
    1634 Elton Road
    Jennings, LA 70546
    Phone: 337-616-7297
    Fax: 337-616-7096
    twoods@jalh.com
  • arobinsoarobinso
    edited May 2016
    I not only referred to coding clinic, but also to my "CDI Bootcamp" info, where HCPro states you can pick up BMI from nursing notes.
  • robert.hodges2robert.hodges2
    Most interesting. I'll have to share this with my coder. I think the problem here may be that while our system automatically calculates the BMI and puts it in the Vital Signs field, the provider doesn't bring the BMI into their note or reference it. Of course I'm just glad if the document the obesity level for now.

    Robert

    "To climb a steep hill requires a slow pace at first."
  • arobinsoarobinso
    edited May 2016
    Let me clarify, our physicians must document "morbid obesity" but then the BMI can be picked up by dietary or nursing notes. Also, in previous audits we must be able to prove we have provided extra resources whether it be in nursing, dietary, PT etc....that is sometimes the difficult part!

    Mandi Robinson, RN, BS, CPC
    Clinical Documentation Specialist
    Trover Health System
    270-326-4982
    arobinso@trover.org
    "Excellent Care, Every Time"
  • twoodstwoods
    edited May 2016
    Yes, that is the case with us. Only our coders will not accept a BMI from the nurse.

    Theresa Woods, MSN, RN
    Clinical Documentation Improvement Specialist
    Jennings American Legion Hospital
    1634 Elton Road
    Jennings, LA 70546
    Phone: 337-616-7297
    Fax: 337-616-7096
    twoods@jalh.com
  • nursronnamnursronnam
    I have had a really hard time in this debate with my coders. The way I interpret the below statement:

    (the physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis).

    As a nurse, it is beyond our scope of practice to establish a diagnosis and thus are not legally accountable which means we can not use nursing documentation. Am I being overly sensitive here??

    Ronna

    Ronna Mahlen, RN, BSN
    Manager of Clinical Documentation
    Overlake Hospital Medical Center
  • dogdog
    I think the confusion comes from the way we read the parenthetical statement within the coding clinic. The coding clinic says that the documentation can come from a clinician who is not the patient's provider. Then it states parenthetically that a provider is defined as the physician or someone who is qualified to make the diagnosis. The misinterpretation is to assume that the words within the parentheses define the 'clinician', rather than the 'provider'. For a sentence that should lead to clarity, it leads instead to confusion.

    Based on the above, our coders do accept BMI documented by nurses. However, I have had to restrain one of our coders from calculating and coding it herself based on the ht/wt she sees in the nursing assessment.

    I am a little curious whether I, as an RN, could calculate the BMI and write it in the chart to go with the physician's documentation of the accompanying disease process. I've never done it, but just wondering.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Arizona Heart Hospital
  • stacy.vaughnstacy.vaughn
    edited May 2016
    You are using the nursing documentation for "more specificity". The
    physician needs to document the obesity, but we can use nursing to
    document the extent of the obesity. The coding clinic directs coders to
    use that information not to make a diagnosis but to create a valid
    picture of the obesity.

    Help?

    Stacy Vaughn, RHIT, CCS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052
  • cbarnescbarnes
    edited May 2016
    Same here....our coders will not accept a BMI from a nurse
  • Unknown
    edited May 2016
    I do not believe the CDS should calculate the BMI. Instead encourage your dietician (or physician) along those lines.

    As a CDS, my goal is to improve documentation - not do the documentation - That happens through education, encouragement and appreciation of what our physicians do document.

    Charlene
  • dogdog
    Charlene, I always ask for the BMI if I don't have it. I've been known to bring very underweight or overweight patients to the dietitian's attention, because for some reason they've not been on their list of patients to see, and they're usually very appreciative.

    I was just mildly curious if as an RN, I could document the BMI if I wanted to. Just as I know of an RN CDS who sometimes writes responses to queries as a verbal order. I have not and would not do that.

    Renee
  • robert.hodges2robert.hodges2
    edited May 2016
    I'm with you Renee. In my role I wouldn't do that either. It sounds like a conflict of interest to me.

    What I've proposed to the providers here (with no response to date) is including BMI when providers import vital signs into their H&P or notes in the electronic system. It would then be seamless to the provider and get the BMI in the record. Then I only have to query on obesity levels based on the existing documentation and the BMI indicators in the ICD-9 manual.

    One day :)

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "Anyone who has never made a mistake has never tried anything new." -Albert Einstein
  • Unknown
    edited May 2016
    I think there is an ethical/compliance issue here. Each facility's policy should address the issue of "verbal responses".

    Technically a 'verbal order’ requires a physician signature.

    Seems to me (and I have only been doing this two years) is it would be a conflict of interest to write responses as a verbal order - what are they ordering? Does not make sense.

    Charlene
  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited May 2016
    The BMI is calculated automatically here when the nurse enters the height and weight. It does not take into account any variables - contractures, pregnancy, amputations, etc. We only assign a code for the BMI from our Registered Dieticians and/or the physician documentation, and only if there is an associated diagnosis (obesity, malnutrition, etc.) documented by the physician.
  • ctrygarctrygar
    edited May 2016
    We do not have electronic medical records here so the bmi is not calculated automatically. Only height and weight appear on the MAR's. What I do as a CDS nurse is when i review the chart I calculate the BMI myself I do not document it in the medical records. If I see a BMI greater than 40 or less than 19 I trigger the dietician to see the patient so theycan have the benefit of seeing a dietician. Then I look to see if physician documented morbid obesity/underweight/ if not then query.

    cheri
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    We only accept BMI documentation from the MD, NP, PA or dietitician. We do not accept BMI documentation from staff nurses. This is how the coding clinic was explained to us from an outside auditor. We do have the BMI on our preprinted progress notes. That has been accepted by auditors - as long as the MD, etc has signed the progress note.
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    We do not take verbal orders as a query response - the physician must document in the chart. We do calculate BMI if it is not in the chart - we place it in our query. We sometimes calculate the GFR - but the MD must actually document the GFR in the progress note.
  • lspryszaklspryszak
    After reviewing the above comments I agree with the majority who state that the BMI can be documented by other than the attending physician (provider) BUT I think the key here is that it must be someone providing direct patient care -- which would exclude the CDS.

    It also appears as though there is a difference of opinion among facilities whether nursing documentation (nurses' notes) is acceptable.

    My recommendation is that when these types of conflicts lead to inconsistent application of rules and guidelines that a facility develop a written policy to address the issue.

    Regarding outside auditors' opinions: they are interpreting the rules and guidelines, too, and unless they can cite legislation or coding rules to support their recommendations, all they are doing is rendering an opinion.
  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    I just requestd the BMI calculation be put in the H&P of our EMR today. It is already acuomatically calculated when the Nurses put in the height and weight but it doesn't account for amputation or volume overlaod in that calculation. I fear unless situation like this can be addressed in the calculation the BMI wouldn't be accurate for the physicians to sign-off their note. I know this is taken into account when the dieticians consult and so I hope it can be formulated for the EMR H&P as well.

    Debbie
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    Our coding compliance manager also agrees that it would not be appropriate to accept staff nursing documentation of BMI - it would need to be the MD, PA or NP.
  • dogdog
    Deb,

    What is your coding compliance manager's source document for refusing to accept nursing documentation of BMI?

    Renee
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    She uses the coding clinic as her guideline.
  • pfowlerpfowler
    edited May 2016
    The BMI automatically calculated and is on the EMR when the unit
    secretary puts in the patient's height and weight. I have been using
    this and the dietician's note to query the physician. Is this correct?


    Patsy Fowler RN, MSN, CCDS
    Certified Clinical Documentation Specialist
    Marion Regional Medical Center
    PO Box 1150
    Marion, SC 29571
    Office 843-431-2044
    Cell 843-431-2863
    Fax 843-431-2475
  • pfowlerpfowler
    edited May 2016
    The BMI automatically calculated and is on the EMR when the unit
    secretary puts in the patient's height and weight. I have been using
    this and the dietician's note to query the physician. Is this correct?



    Patsy Fowler RN, MSN, CCDS
  • dogdog
    Deb,

    I am gently suggesting that she re-read the coding clinic. It states that the BMI can be documented by a clinician who is not the patient's provider, provider being defined as someone who is responsible for establishing the diagnosis. The RN caring for the patient qualifies.

    Renee
  • robert.hodges2robert.hodges2
    edited May 2016
    That's what I use. But my coder still wants the BMI in the providers
    note.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov

    "Anyone who has never made a mistake has never tried anything new."
    -Albert Einstein
  • cstukenbergcstukenberg
    edited May 2016
    I would caution using only a pre-calculated BMI unless you consider the patient. Patients with amputations will be different. We have a pre-calculated BMI but I want the dietician to address it before I just assume this is correct. When she addresses it, she documents it in her notes.

    Colleen Stukenberg MSN, RN, CMSRN, CCDS
    815-599-6820
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  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    We use the nutrition BMI for our patients with amputations since the precalculated BMI is not able to take that into consideration. We also are careful with our CHF and renal patients.
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    RNs do not establish a diagnosis. I would not be comfortable using RN documentation unless the coding clinic specifically states RN documentation is acceptable. If we could accept their documentation, we are lucky the nurses document the ht and wt let alone the BMI.
    I will readdress it with her though.
  • dogdog
    Deb,

    Yes, RNs do not establish a diagnosis. That is why the coding clinic differentiates between a provider (someone who establishes a diagnosis) and a clinician who is not a provider. The RN qualifies as a clinician who is not a provider.

    Clearly, I am not as well versed in coding as your coding manager, or any coder, for that matter. But I am an extreme stickler about language, and I have read this coding clinic's verbiage very carefully. In the end, if your facility does not want to use the nursing documentation, that's obviously their right. And I am sure you have a process to obtain the BMI without nursing's input. For myself, if I need a BMI and for some reason the dietitian hasn't written it, I just query the physician. Our nurses don't document BMI.

    However, I am also thinking about the original poster who was asking to use nursing notes because her dietitian was not always available, and I believe she can safely do that.

    Renee
  • vivian.gannonvivian.gannon
    edited May 2016
    You are correct in that the BMI documentation can be coded from clinician notes (nurse, dietician, etc), however the provider (MD, PA, NP) must document the medical diagnosis that correlates with the BMI ( 40) and any additional clinically significant data in order to capture that as a 'cc'.
    This is a sensitive subject, and our coders like to have additional supporting documentation such as nutritional consult, dietary interventions, counseling, documented need for special equipment ( 'Big Boy bed') etc.. to justify coding the condition.

    Vivian
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    We have the same issues. Our coding manager has instructed the coders not to code from the "banner bar". She is completely supportive of CDI, she just feels like this has not been clarified.
    We query for BMI VERY frequently.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404
  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    Vivian,
    Please refer your coders to coding clinic 3Q 2011, Volume 28, Number 3, pages 4&5. Additional documentation is not required to report as "Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider".

    Cindy
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Its my understanding that this recently changed and now, obesity with a BMI>40 is justification of coding, even without supporting documentation of it impacting patient care and resources.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Oops. You beat me! :)

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404
  • vivian.gannonvivian.gannon
    edited May 2016
    Thank you for the reference! I am adding this for discussion for our next CDI/coder meeting. :)

    Vivian
  • tiffany_susantiffany_susan
    edited May 2016
    We have the same situation. We have worked with our nutrition team and
    implemented the process of paging them when a BMI is greater than 40 or
    less than 19 to obtain their documentation. We have had the same
    discussion regarding the RN and the care partner ... if we can take vitals
    entered by a care partner, why not a height and weight?

    Thank You,

    Susan Tiffany RN, CCDS
    Supervisor Clinical Documentation Program
    Guthrie Healthcare System
    phone: 570-887-6094
    fax: 570-887-5152
    email: tiffany_susan@guthrie.org

    " You only live once, but if you do it right, once is enough!" Mae West
  • cselukecseluke
    edited May 2016
    Yes, that makes sense to me. So much data is entered by the nursing assistants, e.g., I&O, vital signs, etc.
  • catladyrncatladyrn
    I don't agree that it's ok to use BMI strictly from nursing assistant documentation. Nursing assistants, valuable though they are, are not nurses, and unless their documentation is co-signed by a licensed nurse, which tells me the information has been validated, I would not accept it for coding purposes. The other information, such as vital signs, I&O, etc., are supportive findings and are not coded without physician documentation thereof.

    Just my $0.02.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Senior Consultant, CDI/Nursing
    Jacobus Consulting, Inc.
  • mdomineseymdominesey
    edited May 2016
    Asking the dietitians to create a progress note and include the BMI they calculated is a great approach to strengthening the physician's documentation. The physician still needs to note a diagnosis, but the BMI from dietitian or nursing notes is sufficient documentation to code BMI in conjunction with the diagnosis. The dietitian will take into account such factors as the presence of limbs! If one is a double amputee then the height is meaningless when calculating BMI!

    Mark

    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    F: 202.537.4477
    http://www.sibley.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Do your dieticians adjust for amputations? Ours have told us that there is no accurate way to do this and they will not calculate a BMI on an amputee. This is pretty frustrating considering many of our amputees are quite overweight due to mobility issues.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404
  • sharon.colesharon.cole
    edited May 2016
    I agree, it is frustrating that we can't get one on a single amputee. No they usually will not. Although I did ask them once to reconsider on a morbidly obese LLE amputee that weighed in around 650lbs. The resources used as far as the Bigger Boy bed, special order hosp gowns, staff to move her, etc, etc were clearly more than we would have used for a normal weight patient I felt the additional reimbursement was indicated. Since they could get an accurate height, she did calculate the BMI. Her calculation was actually higher than the computer generated 104.85 as she included 60lbs or so for the missing limb. I have never asked for one on a double amputee and that's the only time I asked on a single amputee. 2 employees were hurt while caring for her which also ran her overall "cost" up since now we have to pay for Worker's comp and lost wages too.

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org
  • cstukenbergcstukenberg
    edited May 2016
    There is a calculation that dieticians use for amputees. They should know about it.
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I have been told this before too. They are adamant that there is no accurate way to calculate it and will not do it. Hmmm.....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404
  • mdomineseymdominesey
    edited May 2016
    Livestrong has a good article about this: (calculating BMI for amputees)

    http://www.livestrong.com/article/197827-how-to-calculate-bmi-for-amputee/

    Mark

    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    F: 202.537.4477
    http://www.sibley.org
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