"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?
Kim Saalmuller, RN, MSN, CCDS