Wiki Code Assignment and Clinical Criteria

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siddharthaqa@rediffmail.com

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One of our providers informs us, “morbid obesity (E66.01) can be used with a BMI of greater than or equal to 35.0 with at least one obesity-related condition. Therefore, any patient with hypertension or diabetes and a BMI of 35.0 or greater can be coded as Morbid Obesity with the appropriate BMI code and other diagnoses.”

But according to my understanding, coders are not clinicians and clinical validation must be performed by a clinician. Therefore, a coder cannot code E66.01 (morbid obesity) unless it is documented in the report by a licensed clinician.

If anyone can provide me with some good reference to validate my understanding from an authentic source so that I can forward it to our provider that coder cannot code E66.01 (morbid obesity) if BMI is less than 40 (BMI of greater than or equal to 35.0 with at least one obesity-related condition, diabetes or hypertension)

Thank you in advance.
 
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This guidance comes directly from ICD-10 - you can find it in section I.A.19 in the front of the book:

19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

 
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