When the BMI is below 40, but morbid obesity is documented by the anesthesiologist (no other documentation regarding the patient’s obesity is recorded in the health record), is it appropriate to code morbid obesity or is a query recommended?
Codes for overweight, obesity or morbid obesity are assigned based on the provider’s documentation of these conditions.
Therefore, if morbid obesity is documented, assign code E66.01, morbid (severe) obesity due to excess calories.
While the BMI is used as a screening tool for patients who are overweight or obese, there is no coding rule that defines what BMI values correspond to obesity or morbid obesity since the conditions are coded only when diagnosed and documented by the provider or another physician involved in the patient’s care.
AHA Coding Clinic, Fourth Quarter 2018, pp. 79 – 80
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