no treatment on Query-BMI level over 40

littlebit_62703@yahoo.com

Hello, 

A. Do you automatically generate a query if the BMI level is over 40?

B. I was told that you automatically query and that no treatments are needed to be on a query in order to query for this? Has anyone heard of this before that you do not need the treatment section when you are querying for an associated dx when a BMI level is high? 

Thanks, 

cffernandez44@gmail.com

My understanding is that you don't have to have "treatment" but that it's better to have a diagnosis that supports the coding of the BMI greater than 40.  For example, "obesity," "morbid obesity," "OHS," etc.

evanspx@sutterhealth.org

You may wish to search for and read the article in Coding Clinic, stating that morbid obesity is always significant and reportable.  

How would be the care rendered be impacted by morbid obesity  in an unplanned admit for an extremely obese patient with PNA or a hip fracture, and the obesity requires modifications  to the RN care.  

Would not such a patient be more difficult to treat as compared to someone not obese in terms of bed transfers,  difficulties obtaining clear results with radiological studies, physical exam, and even dosing for tissue penetration.

In my view, all of these factors mean morbid obesity is a risk factor that is always reportable, when present.  The obesity complicates the care for the entire clinical team, and it can’t be ‘cured’ in the inpatient setting.

Paul Evans, RHIA, CCDS

littlebit_62703@yahoo.com

Hello, 

My question is more on how to write a compliant query when a patient's BMI level is over 40 and there is no associated condition documented and there is no documentation of treatment, evaluation, monitoring, additional nursing care, diet orders, assist with anything etc. etc. There is nothing documented in the chart about anything other than the fact the patient's BMI level is High . So on our query template that we use , we  add the  appropriate options of dx at the top and then at the bottom it says clinical indicators, risks, treatment. 

would you still be able to query a provider for an associated condition when the BMI level is high without any documentation of anything else? or is the BMI level alone enough to query a provider for an associated dx?

Thanks, 

evanspx@sutterhealth.org

Part of your responses states ‘document any associated risk’...do you check the ASA rating if they have surgery?

jripplinger

Hi-  I know what you mean, it can seem like there is no specific treatment for that dx, but there are usually some basic care type treatments that can be included in this type of query.
Example:  
Risks: DM, HTN, CAD, 5'11", 336lbs

Symptoms: BMI 46.97, decreased mobility.

Treatment: Dietician following, incentive spirometry, self-regulated re-positioning, skin assessments, PT, OT.

Hope this helps.

pamela.anderson@chs-mi.com

Can a diagnosis for Morbid Obesity be taken if only documented in the ROS?? Especially if supported by other documentation as increased need for care with a BMI of

Comments received from coder at our facility: "CDI can not give obesity as a diagnosis unless the physician documents it as a diagnosis – can’t code from physical/ROS". 

I know there was a change in UHDDS guidelines over the last year or two regarding BMI - to report the BMI and associated dx you need to show significance for this encounter...but can the diagnosis for obesity be taken from the ROS??

Thank you,

Pamela Anderson, BBA, RN

UM/CDI Manager