Obesity Documentation

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Did you know? Obesity and Morbid Obesity are always clinically relevant to the care your patients receive.

Please be sure to document:
1. Your patient’s BMI
2. The corresponding diagnosis of Obesity or Morbid Obesity as a separate problem in your assessment and plan when present

Obesity = patient with admitting BMI > 30
Morbid Obesity = patient with admitting BMI > 35

Per coding guidelines, you only need to document the diagnosis and corresponding BMI to show your patients’ severity of illness. You DO NOT need to document how your patients’ Obesity or Morbid Obesity impacted their care.

“Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider.”
-AHA Coding Clinic, 3rd quarter 2011, Vol. 28, Num. 3, pages 4-5

Download the complete tip, Obesity Documentation.