An inpatient record includes a measured BMI value in the nursing flowsheet and the attending documents obesity. What is the appropriate approach to BMI and obesity coding?
Select an answer to reveal the explanation.
Short Explanation
A BMI number in the flowsheet is useful, but it is not a magic wand that creates an obesity diagnosis by itself. You still need the provider to call obesity (or overweight) out—then the BMI code can ride along as an extra detail.
Full Explanation
BMI codes are generally reported as additional codes when a related diagnosis such as obesity or overweight is documented by the provider. A numeric BMI recorded by nursing may support the BMI code in accordance with guideline allowances for BMI reporting, but the obesity diagnosis itself requires provider documentation. BMI should not be sequenced as principal merely because a value is available, nor should obesity be inferred from BMI alone without a documented diagnosis.