Pediatric Coding Alert

Question: If a patient’s body mass index (BMI) is in the normal range, do we need to include the ICD-10 code for the BMI in the documentation for a well visit?

Codify Subscriber

Answer: There doesn’t seem to be a clear-cut answer to your question.

The American Academy of Professional Coders’ (AAPC) recommendations suggest that you should record BMI as a part of documenting a well visit for patients aged 3 and above, though they don’t say whether that should be limited to documenting only those BMIs out of the normal range (Source: www.aapc.com/blog/39873-recommended-ways-to-document-and-report-a-preventive-visit/).

If a patient’s BMI is in the abnormal range, then it must be documented along with a follow-up plan to address its underlying causes. According to the American Medical Association (AMA), Merit-based Incentive Payment System (MIPS) eligible clinicians must document BMI if it is outside normal parameters, but they must also document a follow-up plan to accompany it (Source: qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_128_MIPSCQM.pdf).

To put it another way, you would document a patient’s BMI if it is relevant to a specific encounter with a provider or if the provider has documented a diagnosis such as E66.- (Overweight and obesity), which contains the instruction to “Use additional code to identify body mass index (BMI), if known.”

However, there may be a couple of good reasons to document any and all patient BMIs. First, documenting normal BMIs would be very appropriate for well-child visits, as they would enable a pediatrician to monitor a child’s growth over time and to give them a baseline by which deviations can be measured.

There is also an argument that your information will contribute to the Healthcare Effectiveness Data and Information Set (HEDIS), which the National Committee for Quality Assurance (NCQA) uses to develop performance measures for healthcare in this country. In other words, data gathered on your patients’ BMIs for HEDIS will be used to influence health care policy and improve health outcomes for all.