Final Coding Project
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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 established office visit – moderate level.
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. This code states office or other outpatient visits for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a high level of medical decision-making. The time code selection for this is 20-29 minutes. The patient is in an office setting and has been at this doctor’s office previously, so the patient is established. The patient's medical history was reviewed. The comprehensive examination was the mammogram. The doctor discussed treatment options like surgery, PET scans, and CT cans and even referred
to a plastic surgeon and a therapist. This would indicate a high complexity
of medical decision-making. The time
spent between the doctor and patient is 25 minutes.
Week 4: Jane Smith’s Imaging Services
MCCG146 – Portfolio Project Coding Template 2
Provide CPT Code(s) and modifier if applicable for the professional component provided for the Imaging Services:
PET with CT 78815-26
Provide the HCPCS Code(s) for the Radiopharmaceutical Agent Injected during Imaging Procedure:
A9952
Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi
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, A55052
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.
78815 is described as positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization
imaging, skull base to mid-thigh. In my CPT book, I searched in the index for Positron emission tomography (PET) with computed tomography (CT). I was given 2 codes. 78814 and 78815. I looked
up both codes and 78814 is only for limited areas like chest, head/neck. Code 78815 is specifically for the skull base to mid-thigh, which is the exact area the imaging was taken in this case. This would also have the modifier 26 because professional component
Week 5: Jane Smith’s Pre-Op Lab (Report 1) and Outpatient Surgery (Report 2)
MCCG146 – Portfolio Project Coding Template 3
Provide CPT Code (s) for Pre-Op Lab Orders (Report 1)
85025, 80053, 87635, 85014
Provide the CPT Lab Codes that have a
CCI Code Pair Edit (PTP) and include the CCI PTP associated modifier.
85014 and 85025 – have CCI pair edit.
Modifier 9-Not applicable
Provide CPT Code(s) for Surgeon’s Outpatient Surgery Services 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.
I individually looked up each lab testing for the cpt codes. For the CCI, PTP codes I used the NCCI website that has the tables to look up the codes. I typed each one in and searched for the code in column 1. Then I looked in column 2 for the other codes I listed. I only found one and the modifier for it. I used the surgery that
was given in the report to find the cpt code and
modifier for it.
Week 6: Jane Smith’s Inpatient Consultation with Procedure
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MCCG146 – Portfolio Project Coding Template 4
Provide CPT Evaluation and Management (E/M) Code: 99284
Provide CPT Procedure Code for Procedure (s) and modifier if applicable:
93010
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. the patient was seen in the ER after being transported by ambulance and arriving at the ED. ED e/m range 99281 – 99285. This visit supports a level 4 Moderate ED visit. Provider ordered a 12 lead ECG and performed the interpretation. Multiple electrodes are placed on a patient's chest to record the electrical activity of the heart. A physician interprets the findings. Report 93000 for the combined technical and professional components of an ECG; 93005 for the
technical component only; and 93010 for the professional component only.
Moderate Level Medical Decision Making (2 out of 3)
Nature of Presenting Problem: 1 Undiagnosed new problem with uncertain prognosis
Assessment: Unknown etiology for recent syncope is mentioned.
Plan: The plan includes ordering a 12-lead ECG, reviewing and interpreting the ECG results, and recommending admission for further testing and observation.