Location of Obesity documentation

BeckyA

Hello all,

We are having a conversation with our coding staff regarding the coding of Obesity in order to capture BMI>40. We have previously been taking this documentation from anesthesia documentation as it is documented as "Obesity Class III" next to the actual BMI in the banner bar of the anesthesia record for patients who have OR procedures. We have learned that this is an automatically populated location in the banner bar from the BMI. Would you capture this as a diagnosis if it is automatically populated and not manually entered by the physician or would you query the physician for the documentation of Obesity? 

Thanks for any help!

evanspx@sutterhealth.org

Even if/when it is ‘entered automatically”, if it is authenticated by am MD, IMO, this constitutes documentation to consider for data reporting.  It is  wise to corroborate the obesity and BMI status with other portions of the record, such as an RD/RN notes,  as sometimes there may be dissonance, and 3rd parties will try to cite any inconsistencies as lack of adequate documentation.  But, the means in which the information is entered is not pertinent in my opinion as long as the information is consistent with other evaluations and is authenticated by a provider authorized to render and record a diagnosis.

I’d ask coding how or why they made a unilateral decision to apparently chose to ignore what has been documented by an MD?

Paul Evans, RHIA, CCDS