Week 6 Portfolio
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Feb 20, 2024
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MCCG146 – CPT and HCPCS Level II Coding Portfolio Project Coding Template Week 3: Jane Smith’s Physician Office Visit
Provide CPT Evaluation and Management (E/M) Code: 99214
Reflection/Method on Code Selection – Describe in detail the steps/method you took to code the services correctly
and to ensure the services are coded correctly. My first step was to read through the physicians' medical documentation. Based on the documentation, I saw that the total time spent was 25 minutes, which is 92213.
As I reviewed the physician’s notes and looked at the medical decision-
making table in more detail, I concluded this was a moderate level of decision-making since the patient was diagnosed with a chronic illness with an exacerbation (which is recurrent) and the physician also ordered a CT PET scan to ensure that
the cancer had not metastasized.
MCCG146 – Portfolio Project Coding Template 2
Week 4: Jane Smith’s Imaging Services
Provide CPT Code(s) for services performed by Dr. Clark and modifier if applicable for the professional component provided for the Imaging Services:
78815
Coding for the Supply Code, provide the HCPCS Code(s) for the Radiopharmaceutical Agent Injected during Imaging Procedure:
A9552
Using Medicare’s website, https://www.cms.gov/medicare-
coverage-database/search.aspx
determine whether or not the CPT code has an active LCD and Answer the following question: - Does the Imaging Procedure CPT code you selected have an active Article/LCD? Yes/No? If yes, Identify Article/LCD. Yes.
Article Number: A58559 Title of Article: Independent Diagnostic Testing Facilities (IDTF): Coding and Billing Type of Article: Coding and Billing Date of Original Effectiveness: April 1, 2021 Effective Date of Revision: January 1, 2022 Final Revision Date: May 31, 2022 Date of Retirement: N/A
Reflection/Method on the Code Selection. Describe in detail the steps/method you took to code the services correctly and to ensure that the services are coded correctly.
In my CPT manual, I discovered CPT code 78815 in the Orange Radiology section. PET with recently acquired CP
for anatomic localization imaging and attention correction is the description of this code.
MCCG146 – Portfolio Project Coding Template 3
Week 5: Jane Smith’s Pre-Op Lab (Report 1) and Outpatient Surgery (Report 2)
Provide CPT Code (s) for Pre-Op Lab Orders (Report 1)
1.85025
2.80053
3.87635
4.85014
Provide the CPT Lab Codes that have a
CCI Code Pair Edit (PTP) and include the CCI PTP associated modifier.
According to CCI modifier/policy indicator 1, 85025 with 85014 is allowed.
Provide CPT Code(s) for Surgeon’s Surgery Services by Dr. Wells and modifier if applicable (Report 2):
19307-LT
Reflection/Method on the Code Selection. Describe in detail the steps/method you took to code services and to ensure the services are coded correctly.
Given that the patient was having an outpatient left mastectomy with axillary lymphadenectomy, I was given the CPT code 19307-LT for the procedure. The location of the point of greatest counts in the left axilla marked the beginning of the procedure, according to the report. The left breast's nipple-areolar complex was then included in an incision. The dissection was performed superiorly to the level of the clavicle, inferiorly to the level of the inframammary fold, medially to the lateral border of the sternum, and laterally to the anterior border of
the latissimus dorsi muscle. The pectoralis major muscle's fascia was used for dissection. After then, the anterior chest wall's fascia and breast tissue were mobilized.
The surgical pathologist removed the specimen and, for orientational considerations, sutured the area around the axillary tail. This informs me that the patient underwent a modified radical mastectomy that excluded the pectoralis major muscle
but included the axillary lymph nodes
and pectoralis minor muscle, either way.
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MCCG146 – Portfolio Project Coding Template 4
Week 6: Jane Smith’s Encounter with Procedure
Provide CPT Evaluation and Management (E/M) Code for services performed by Dr. Scott: 99284: For the first observation and inpatient admission
Provide CPT Procedure Code for Procedure (s) and modifier if applicable:
93010- 12 lead EKG lead, including report and
interpretation only.
Reflection/Method on Code Selection. Describe in detail the steps/method you took to code the services and to ensure the services are coded correctly. Using my codebook index, I searched
for the main terms needed to locate the CPT code. Since she was admitted to observation following an emergency room visit, the CPT code ranged from 99221-99223. Having a low level of decision-making, the medical history of the patient needs to be appropriate. The patient and her previous hospital records were reviewed in only 30 minutes.