"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

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