Wiki HCC capture from the exam in an office note

[Ringo3769]

Hello,

I'm hoping for some clarification on pulling HCC codes from the exam in an office note. I understand capturing the obvious, like amputations, but my question is focused on obesity. If the provider states the patient is obese or morbidly obese in the exam, but does not include any other MEAT or TAMPER in the rest of the document, is that enough to capture the code? Can you provide a definitive source? I have a 2018 AAPC CRC study guide but the does not address this specific situation and I'm hoping someone has some updated guidance.
Thank you!

 

[lcourt6]

Hi,
From my understanding, to code for obesity, the provider needs to diagnose the patient with obesity. I take that to mean that MEAT or TAMPER has to be met and the diagnosis of obesity meets the definition of a reportable diagnosis.

 

[wisibyusha]

Hi, this is what I found: if a patient is diagnosed with obesity of BMI >= 40, the coder should review the medical record for co-morbid conditions affecting the health of the patient to support the reporting of morbid obesity. Please check the attachment for further clarification.