Pediatric Coding Alert

Question: If a patient’s body mass index (BMI) is in the normal range, do you still assign it to the patient’s chart? The ICD-10 guidelines state “BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity).”

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Answer: While you can interpret the ICD-10 guidelines for the Z68 (Body mass index [BMI]) codes as telling you to only record a BMI and its associated ICD-10 code if it was related to a diagnosis — suggesting only abnormal BMIs should be reported — the guidance only affects the ICD-10 BMI codes, and not reporting the actual BMI itself.

In fact, there are some good reasons for documenting normal BMIs. First, a patient’s BMI should be documented at every 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual including an age and gender appropriate history, examination …) encounter as part of the patient’s exam. Doing so enables your pediatrician to monitor a child’s growth over time and to give them a baseline by which deviations can be measured.

Second, BMI information contributes 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. So, data gathered on your patients’ BMIs for HEDIS will be used to influence healthcare policy and improve health outcomes for all.