MCCG100 Week Six Case Scenarios - Jocostia Simmons

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Week Six: Case Scenarios MCCG100: Intro to Reimbursement & Coding Jocostia Simmons December 8, 2023
1 Week Six Case Scenarios Scenario 1 A patient presents with right upper quadrant pain, nausea, and vomiting. The physician examines the patient, completes and abdominal ultrasound of the right upper quadrant. Examination and ultrasound show calculi in the gallbladder. The doctor diagnosed the patient with cholecystitis. The physician determines that the patient will need to have a Cholecystectomy. The procedure is scheduled. Respond to the questions below in an essay format, double spaced and at least a minimum of 100 words in length. 1. Are the signs and symptoms presented consistent with the provider’s diagnosis? What coding classification system would be used to assign a diagnosis? 2. Explain what procedures were performed to prove this diagnosis. What coding classification system would be used to assign a code for the procedure(s) performed? 3. Explain the importance of accurately linking the correct diagnosis and procedure codes to achieve medical necessity. Was medical necessity met in this scenario? Why or why not? The signs and symptoms presented are consistent with the provider’s diagnosis. An examination and ultrasound were conducted to prove the diagnosis to be true. ICD-10-CM would be the coding classification system used to assign a diagnosis. The coding classification system that would be used to assign a code for the physical examination performed is CPT (Level I HCPCS). This is also called an Evaluation and Management CPT code. The ultrasound would be coded with a radiology CPT code. The importance of an accurate link to the correct diagnosis and procedure codes to achieve medical necessity can be linked to several things. It demonstrates that the patient will receive appropriate care that in fact addresses his or her health issues. It increases the chances that (insurance) payors will compensate for the cost of services provided to the patient which is needed to continue the flow of the Revenue Cycle within a healthcare organization. It also serves as a reflection on the provider’s competence and the level of expertise. The medical
2 necessity in this scenario was not met because of other options by the provider that should have been presented. While a Cholecystectomy is one way to eliminate the suffering from gallstones, there are other non-surgical options that are significantly less expensive and allows the patient to keep their gall bladder: acid pills that dissolve gallstones, shock-wave treatments to dissolve gallstones, injection of methyl tertiary-butyl (MTBE) into the gallbladder to dissolve gallstones and other non-surgical (non-invasive) procedures and treatments. These diagnoses and procedure steps would be denied on a claim. Scenario 2 A patient presents with fever and a sore throat. The patient states they have had a sore throat for 5 days. The physician performs a rapid strep test that is negative. The doctor diagnosis patient with strep throat. Respond to the questions below in an essay format, double spaced and at least a minimum of 100 words in length. 1. Are the signs and symptoms presented consistent with the provider’s diagnosis? What coding classification system would be used to assign a diagnosis? 2. Explain what procedures were performed to prove this diagnosis. What coding classification system would be used to assign a code for the procedure(s) performed? 3. Explain the importance of accurately linking the correct diagnosis and procedure codes to achieve medical necessity. Was medical necessity met in this scenario? Why or why not? The signs and symptoms presented are consistent with the provider’s diagnosis of strep throat, however the result given from the rapid strep test proves the diagnosis to be untrue. ICD-10-CM would be the coding classification system used to assign a diagnosis to this patient. The Coding classification system that would be used to assign a code to the rapid strep test would is CPT (Level I HCPCS), using a specific pathology/lab code.
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