MCCG222 - Portfolio Project Coding
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Dec 6, 2023
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MCCG222 – Advanced CPT and HCPCS Level II Coding
Portfolio Project Coding Template
Week 2:
Rodney Balbo’s Emergency Room Visit
ICD-10-CM Code(s):
S01.01XA laceration without foreign body of
scalp initial encounter
CPT Code(s):
1
2002
simple repair of superficial wounds to
the scalp, neck, axillae, external genitalia,
trunk, and/or extremities (including the hands
and feet) that are 2.6 to 7.5 cm in size.
HCPCS Level II Code(s):
J0131 injection acetaminophen not
otherwise specified
A0999 unlisted ambulance service.
Reflection: When completing this scenario I first went to the tabular list in
my ICD-10-CM code book and I looked up laceration and looked for scalp
and I found the code S01.01 . I went to the table and found laceration
without foreign body of scalp. I saw that the code was supposed to have 7
characters. When looking at the emergency room visit note it did not
specify if this had happened before. So I coded it as a initial encounter so
that code is S01.01XA. When looking for the CPT code it was a little difficult
for me to find. When I first looked it up I was looking at laceration repair
and it did not say anything about scalp laceration repair. So then I went to
wound repair and looked up scalp. There were different levels of wound
repair. It was specified in the note if it was complex or intermediate. I chose
simple and the codes were 12001,12002,12004-12007. When looking at
the codes I noticed that there were different measurements for the repair, I
did see that it was 3 cm. So I chose the code 12002 because the
measurements were between 2.6 cm to 7.5 cm. Lastly I went to my HCPCS
level II code book I was looking for the Tylenol medication that was
administered to the patient. I looked up acetaminophen and the codes
listed were J0131, J0134,J0136. I chose J0131, all the other codes did not fit
this scenario. I also looked up how to patient arrived at the emergency
room which was by ambulance. The codes listed were A0021-A0999. Out of
all the codes only A0999 would be the correct code.
Week 3:
Rodney Balbo’s Office Visit
MCCG222 – Portfolio Project Coding Template
2
ICD-10-CM Code(s):
I10, G44.309, W182XXA, R53.83
CPT Code(s):
99215
HCPCS Level II Code(s):
N/A
Reflection: For this scenario, I first went to the tabular list and looked up
hypertension and found the code I10, G44.309 for the headaches post-
traumatic from his fall at home that he was seen in the emergency room.
W18.2XXA for the fall-in-the-shower initial encounter and R53.8 because of
his feeling drowsy. The patient was an established patient who had a
history of controlled hypertension and came in office with headaches. The
patient is having a post traumatic headache, this along with his history of
hypertension would make him a high complexity patient so I choose 99215.
Because of the information relayed to the doctor, he scheduled an MRI with
an outpatient office. The patient has a history of hypertension which is
controlled by medication based on the official coding guidelines the code
ranges from I10-I15. The assessment and plan for the patient was
headache with drowsiness. There was no HCPCS II code in this scenario.
Week 4:
Rodney Balbo’s Imaging Service
ICD-10-CM Code(s):
G44.309, R40.0
CPT Code(s):
70552
HCPCS Level II Code(s):
A9585
LCD Article ID Number:
A57204
Reflection:
The patient is diagnosed with post traumatic headache and drowsiness he
is scheduled to have an MRI of his brain with contract. The patient was
given 0.1 ml of Gadavist. Based on the LCD article which is about MRI and
CT scans of the Head and Neck shows that the documentation from the
record meets the medical necessity for the MRI, as both diagnosis codes
are found within the article.
Week 5:
Rodney Balbo’s Outpatient Surgery #1
MCCG222 – Portfolio Project Coding Template
3
ICD-10-CM Code(s):
CPT Code(s):
HCPCS Level II Code(s):
APC:
Reflection:
Week 6:
Rodney Balbo’s Outpatient Surgery #2
ICD-10-CM Code(s):
CPT Code(s):
HCPCS Level II Code(s):
APC:
Reflection:
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