Coding and Obesity: Room to Grow

摘要

id="p1">Introduction: Obesity is the leading health problem in the United States. Providers often fail to document obesity in patients whose body mass index (BMI) is more than 30. id="p-2">Methods:Using a structured data query of the military health system electronic medical record, we determined the BMI and presence of an associated International Classification of Disease code in a cohort of more than 3 million patients. id="p-3">Results:Fifteen percent of patients (482,628) had a BMI exceeding 30. Of those patients with a BMI more than 30,78,776 (16%) had an associated International Classification of Disease 9 code documenting obesity in their record. id="p-4">Conclusion:Coding and documentation of obesity is inadequate. This has implications for delivery of preventive counseling and efforts to mitigate rising trends in obesity. class="kwd-group KWD">

>class="kwd-search" href="/search?fulltext=Coding&sortspec=date&submit=Submit&andorexactfulltext=phrase">Coding

>class="kwd-search" href="/search?fulltext=Delivery+of+Health+Care&sortspec=date&submit=Submit&andorexactfulltext=phrase">Delivery of Health Care

>class="kwd-search" href="/search?fulltext=Obesity&sortspec=date&submit=Submit&andorexactfulltext=phrase">Obesity id="p-5">Despite the well-recognized increase in obesity, weight status is documented for only 1 of 5 obese patients presenting for care.id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1 One in 3 obese adults have not received specific advice from their physician to address their weight.id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2 Complications of obesity make it the leading cause of preventable death in the United States.id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3 Failure to document the patient's weight status is associated with lower rates of physician counseling and recommendations regarding appropriate weight loss.id="xref-ref-1-2" class="xref-bibr" href="#ref-1">1 id="p-6">The Military Health System (MHS) uses an integrated electronic medical record (EMR) that records patient height, weight, body mass index (BMI), and International Classification for Disease (ICD-9) code at every clinical encounter. Using this data architecture, we sought to determine how many obese patients had a corresponding (ICD-9) entry for obesity in their medical record.