Capturing a patients' BMI

kelley.huff@wjmc.orgkelley.huff@wjmc.org
in CDI Talk Archive
What are everyone's thoughts?

Capturing a low (< 19) or high (> 40) BMI with no physician documentation as to either malnutrition or obesity. If there is dietician involvement, supporting labs, intervention with diet education/supplements ----

Would you code the BMI with no physician documentation of the malnutrition or obesity? Would you code the BMI even if there was no other supporting information?

We do query the physician but some times we get no answer and when this happens our coding team will not code the BMI.


Kelley Huff, RN
CDI specialist
West Jefferson Medical Center

Comments

  • ddouthitddouthit
    edited May 2016
    Kelley,

    Per Coding Guidelines and Coding Clinics(see below) you may not assign a BMI unless physician documents obesity, cachexia, malnutrition etc.


    Body mass index reporting clarification
          Coding Clinic, Second Quarter 2010 Page: 15 Effective with discharges: July 7, 2010

    Question:

    There has been some confusion as to whether nursing staff documentation is acceptable for assigning the body mass index (BMI). Since hospitals are allowed to code the BMI based on the dietitian’s documentation, it would seem reasonable to assign the BMI based on the nurse’s documentation as well. Can coders use nursing documentation to assign the BMI?

    Answer:

    Yes, the BMI may be assigned based on medical record documentation from clinicians, including nurses and dietitians who are not the patient’s provider. As stated in the Official Guidelines for Coding and Reporting, BMI code assignment may be based on medical record documentation from clinicians who are not the patient’s provider, since this information is typically documented by other clinicians involved in the care of the patient. Dietitians were only mentioned as an example of a clinician that might document BMI information.

    However, the associated diagnosis (such as overweight, obesity, or underweight) must be documented by the provider.

    Refer to the Official Guidelines for Coding and Reporting for additional discussion.


    © Copyright 1984-2012, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

    Dorie Douthit, RHIT,CCS
    CDI Program/HIM
    706-389-3364
    St. Mary's Health Care System
    1230 Baxter Street
    Athens, Georgia 30606
  • mdomineseymdominesey
    edited May 2016
    ICD9 Guidelines require a diagnosis in order for the BMI to be coded. The BMI means nothing without the corresponding diagnosis. To include it in a code set without the diagnosis (obesity, morbid obesity, cachexia, malnutrition, anorexia, etc) will raise a red flag during the data mining the RACs and other organizations do.

    Be safe! Always query for clinical significance (i.e. a corresponding diagnosis)

    MND


    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    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
    mdominesey@sibley.org
    http://www.sibley.org
  • robert.hodges2robert.hodges2
    edited May 2016
    My understanding is the BMI cannot be coded without a supporting diagnosis. I will query for the "clinical significance" of a high or low BMI which includes that the provider must document a diagnosis if it is significant. Of course a nice dietician note indicating signs of malnutrition or obesity does help.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    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
     
    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    It is my understanding that they need to state a corresponding dx in order for the BMI to be coded. I find that it is exceedingly rare that obesity (in general) is not mentioned in a morbidly obese patient. They do not need to state that the patient is morbidly obese in order to code the BMI, Just obesity.

    The most recent CC (that I know of) on the subject clarifies that obesity is ALWAYS significant and no longer requires documentation of medical significance in order for it to be coded.

    Coding Clinic, Third Quarter 2011 Pages: 3-4 Effective with discharges: September 23, 2011
    Question:
    If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only without any additional documentation to support clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance such as evaluation, treatment, increased monitoring, or increased nursing care, etc., for this condition.
    Answer:
    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. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented.
    Refer to Coding Clinic, Third Quarter 2007, pages 13-14, for additional information on coding chronic conditions.
    © Copyright 1984-2011, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • Unknown
    edited May 2016
    I would query the physician for abnl clinical findings- put CI as noted.
    And get him/her to place dx on chart.

    Jamie Dugan RN
    Clinical Documentation Improvement Specialist
    Baptist Health System
    office:904-202-4345
    cellular: 904-237-7253
    Business Email-jamie.dugan@bmcjax.com
    cdis.icd10@bmcjax.com
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    As far as querying, we list the clinical indicators (height, weight, BMI, and whatever else we have) and ask for a corresponding dx (morbid obesity, obesity, underweight, etc, along with other, unable to determine)

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
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