Obesity is a common, serious and chronic disease. The treating/rendering provider must document obesity, morbid obesity, or any other diagnosis-related code from a body mass index (BMI) measurement.

When documenting obesity, it’s important to specify:

• Type: Overweight, obese, morbidly (severely) obese, morbid obesity with alveolar hypoventilation, obesity hypoventilation syndrome
• Cause: Due to excess calories, drug induced obesity (specify drug)
• Associated comorbid conditions: Endocrine related, hypertension etc.
• Weight and the BMI: Documenting the BMI alone is not sufficient; a weight related condition is required to be present in documentation
• Additional tips: BMI should never be a primary diagnosis, per ICD-10-CM. BMI may be documented and accepted from any clinician (Reference: Coding Clinic, Q4, 2018, page 72-73, 77).

Recommended documentation practices for obesity and morbid obesity:

Coders cannot infer associated weight diagnosis from a BMI value or percentage, it must be documented by the clinician within the medical record. Documentation of obesity includes the cause and if the obesity is considered morbid. Specificity of BMI is best documented when the description for underweight, overweight or obesity is present in providers documentation.