AHA Coding Clinic® for ICD-9 - 2011 Issue 3; Ask the Editor

Clinical Significance of Obesity

If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only without any additional documentation to support clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance such as evaluation, treatment, increased monitoring, or increased nursing care, etc., for this condition. ...

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