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mchaidez

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Hello,

One of our physicians documented Morbid Obesity, BMI 40-45 on patients H&P and Discharge Summary , but when I checked Medical records patient BMI was 32.44.
Can I still code Z68.32- even if the Physician Document BMI 40-45?
 
That sounds like conflicting documentation. One thing that I could think of is that patient's weight has changed since they first gave the patient a BMI 40-45. Now, if there is no documentation to support patient has lost weight and is now at 32.44, you will need to query the provider for the conflicting documentation in regards BMI 40-45 vs 32.44.

Hope this helps!
 
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