"History of Obesity"

A question came up recently regarding coding of Obesity when only documented or listed as a History. This seems like it should be a simple concept, but we have heard varying opinions. Some subscribe to the idea that a "history" could be resolved, so we should query, but if the associated BMI supports the diagnosis, should we capture the obesity code?

Should we capture Obesity/Morbid Obesity and the associated BMI if the diagnosis is listed in the body of a note? Example: "Patient presents with shortness of breath, has history of COPD, Seizures, and Obesity..."

Should we capture the diagnosis if only listed in the PMH box?



Pneumonia 2/27/2008


COVID-19 10/20/2020

Morbid Obesity


Kim Saalmuller, RN, MSN, CCDS

Sign In or Register to comment.