Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician, like the dietitian or nurse? I thought that we could use such ancillary documentation for clinical indicators supporting our physician query, but the treating physician needed to document the BMI. Can you help clarify this for me?
A: Documentation of the BMI can be taken by either the physician or a nonphysician (such as a dietitian or nurse). It is usually taken from the documentation of a nurse or dietician, as this has become a standard piece of their admission assessments (Nursing staff routinely will weigh the patient during admission.)
The important piece to remember is that the physician must first document the clinical condition (such as obesity) to allow us to then code the BMI. For example, a BMI greater than 40 will provide a CC. But we cannot code the BMI greater than 40 without first having the documentation of obesity from the physician. Obesity alone will not provide a CC.
Editor’s note: Laurie Prescott, MSN, RN, CCDS, a CDI education specialist for HCPro, a division of BLR, in Danvers, Massachusetts, answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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