AHA Coding Clinic® for ICD-9 - 2011 Issue 3; Ask the Editor
Clinical Significance of Obesity
If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only without any additional documentation to support clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance such as evaluation, treatment, increased monitoring, or increased nursing care, etc., for this condition. ...
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Article Overview
This article addresses a common coding question about documentation of obesity and morbid obesity in the record, with attention to clinical significance and reportability. It is relevant to coders, CDI professionals, and compliance teams who review chronic condition documentation and the role of BMI-related support in coding decisions. The article also points readers to Coding Clinic guidance on chronic conditions.
Why This Topic Matters
Obesity-related diagnoses are frequently documented in hospital records, and coders need to know when the documentation is sufficient for reporting. The article explains the general documentation context considered for these conditions and references supporting guidance that affects coding review workflows.
What You Will Learn
- How obesity-related documentation is discussed in the context of clinical significance
- What general types of supporting documentation are referenced in relation to chronic conditions
- How BMI documentation is discussed as part of the coding discussion
- Where to look for additional official guidance on chronic condition coding
Who Should Read This
- Medical coders
- Coding auditors
- CDI specialists
- Compliance professionals
- Healthcare documentation reviewers
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