There has been some confusion as to whether nursing staff documentation is acceptable for assigning the body mass index (BMI). Since hospitals are allowed to code the BMI based on the dietitian's documentation, it would seem reasonable to assign the BMI based on the nurse's documentation as well. Can coders use nursing documentation to assign the BMI?
Yes, the BMI may be assigned based on medical record documentation from clinicians, including nurses and dietitians who are not the patient's provider. As stated in the Official Guidelines for Coding and Reporting, BMI code assignment may be based on medical record documentation from clinicians who are not the patient's provider, since this information is typically documented by other clinicians involved in the care of the patient. Dietitians were only mentioned as an example of a clinician that might document BMI information.
However, the associated diagnosis (such as overweight, obesity, or underweight) must be documented by the provider.
Refer to the Official Guidelines for Coding and Reporting for additional discussion.