BMI Coding

cselukecseluke
in CDI Talk Archive
Can anyone give me advice on this issue? Here's the deal: Our electronic
medical record automatically calculates and records a BMI when a
patient's height and weight are entered. The height and weight are often
entered by nursinbg assistants or ED techs. Per our hospital policy and
state nurse practice act, all assistive personnels' documentation is
subject to oversight by RN's. Our coders have interpreted Coding Clinic
2nd qtr 2010 p. 15 to mean that they can only code BMI if is documented
in the record by a "licensed provider".



I contend that, assuming the treating provider has documented an
associated condition such as obesity, the BMI could be coded from the
medical record. Opinions, please. Also, if you can cite references, I
would greatly appreciate it.



Cathy Seluke, RN, BSN, ACM, CCDS

Supervisor Clinical Documentation Compliance

MaineGeneral Medical Center

149 North Street

Waterville, ME 04901

Phone (207) 872-1796

Fax (207) 872-1519

Cathy.Seluke@mainegeneral.org





"That's why erasers were put on pencils."

--Robert Lovely c. 1960 when asked if he ever made
mistakes

Comments

  • cstukenbergcstukenberg
    edited May 2016
    Our computer system automatically calculates the BMI but we request the dietitian to document it. They are more knowledgeable in this field even compared to nursing. They even have formulas that they use to adjust the BMI for amputations, etc. I would want the BMI documented either by the physician or the dietitian.
    In addition, if the wrong height or weight is entered into the computer, the BMI will be calculated off this which would be wrong.

  • robert.hodges2robert.hodges2
    edited May 2016
    I had that issue here, but came up with a cheap solution. When providers import vital signs into their note it now includes the calculated BMI. Two advantages here. First, the provider doesn’t have to document the BMI. Second, because it is in their note, I can query for the clinical significance of the BMI and if significant ask for that along with the appropriate diagnosis. So far it’s working out very well since providers here were putting in the diagnosis, but not the BMI and both elements are needed.



    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



    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens



  • twoodstwoods
    edited May 2016
    Our Docs have now learned to document the BMI with the dx. When it is Obesity, the nursing notes show patient needs assist of 2 or more persons along with any other debility noted.

    Theresa Woods, RN, MSN
    Jennings American Legion Hospital
    1634 Elton Road
    Jennings, La 70546
    Phone: 337-616-7297
    Fax: 337-616-7096
    twoods@jalh.com
    "Attitude is a little thing that makes a big difference." Winston Churchhill
  • catladyrncatladyrn
    Our EMR software does the same thing, i.e., calculates the BMI. But the assessment is logged under the RN signature, which is good enough for us and for our coders. Totally not getting why those coders would require a "licensed provider" to document the BMI when that's not what the coding clinic says. It says flat out that the BMI may be assigned by clinicians who are not the patient's provider; the associated dx must be documented by the provider.
  • fentona@bronsonhg.orgfentona@bronsonhg.org
    edited May 2016
    very well stated.

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