BMI

sarah_wicks@urmc.rochester.edusarah_wicks@urmc.rochester.edu
in Clinical & Coding

If a patient’s BMI is in the H&P, but there is no current weight in the chart, can CDI query for a weight-related diagnosis just based on the BMI listed in the chart?

Sarah Wicks, RN, MS, MBA

SMH Clinical Documentation Improvement Program Manager

HH Clinical Documentation Improvement Program Manager

Utilization Management | Strong Memorial Hospital | Highland Hospital

P: 585.602.1755 | F: 585.276.2801

Comments

  • Rutland2023Rutland2023

    Hi Sarah,

    I would look towards the dietician assessment as well and see what they have to say. If the BMI is less than 20, it could just be the patient is a smaller stature person vs having malnutrition. I also call the unit the patient is on and ask them to place a current measured BMI in the chart. I would only query after those measures if the providers do not discuss malnutrition. A BMI of will give a CC regardless of the diagnosis of obesity providing the provider has documented it in the H&P.

    Tracie H

    RRMC

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