"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?
PMH:
Asthma
Pneumonia 2/27/2008
Epilepsy
COVID-19 10/20/2020
Morbid Obesity
Thanks,
Kim Saalmuller, RN, MSN, CCDS
Comments
No. It would need to be queried to clarify. The coding clinc regarding chronic conditions and coding when documented as history of pertain to diagnoses that never go away. Obesity goes away. If the BMI supports still being present, then history of should be clarified.
Being overweight may place a patient at increased risk for certain medical conditions. However, overweight may only be reported when it meets the definition of a reportable diagnosis per Section III, Reporting Additional Diagnoses, of the ICD-10-CM Official Guidelines for Coding and Reporting . Neither the code for overweight nor the BMI code is assigned when there is no documentation that the diagnosis "overweight" meets the definition of a reportable secondary diagnosis. Obesity and morbid obesity are always clinically significant and should be coded and reported when documented by the provider. The BMI code may be reported with these conditions when BMI is documented. BMI codes should not be assigned during pregnancy.