RE: [EXTERNAL] RE:Morbid Obesity along with joint replacements
Thinking more clearly about this issue I would say that the coding clinic is not in opposition to the UHDDS guidelines. The coding clinic just establishes that increased management is implied regardless of specific documentation from the provider. UHDDS does not say impact must be documented so generally it is up to the coder to determine significance (to a degree). The older coding clinic on BMI explains this fairly well stating that "To meet the criteria for a reportable secondary diagnosis, the BMI would need to have some bearing or relevance in turns of patient care.". It does not say that the physician has to specifically explain the significance. The coding clinic just clarifies that for the coder explaining that this condition always impacts patient care/risk.
Assigning body mass index codes
Coding Clinic, Fourth Quarter 2008 Page: 191 Effective with discharges: October 24, 2008
Ask the Editor
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
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.
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
Assigning body mass index codes
Coding Clinic, Fourth Quarter 2008 Page: 191 Effective with discharges: October 24, 2008
Ask the Editor
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
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.
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