Body Mass Index (BMI) Assessment
BMI predicts health risks in adult patients who are both under- weight and overweight.* BMI is a safe, non-invasive test, which, when combined with clinical assessment of the patients, can provide critical information regarding patients’ nutritional status.
- Although non-physician staff may calculate and record the BMI, it is up to physicians to provide the corresponding diagnosis (e.g., underweight, protein-calorie malnutrition, obesity).
- The combined use of BMI, careful history and exclusion of confounding factors (e.g., ascites) provides a framework for nutritional intervention when necessary.
Coding and Documentation Guidance
The ICD-10 coding rules require that both the BMI and a narrative description of the meaning of the BMI be documented and coded. BMI alone cannot be coded.
Physicians must interpret the BMI in their documentation, noting if patients are of normal weight, underweight, cachectic, obese, morbidly obese, etc.
*Alpers DH, Klein S. Approach to the Patient Requiring Nutritional Supplementation. In Yamada T, Textbook of Gastroenterology, 4th edition. Baltimore: Lippincott Williams & Wilkins, 2003