MCCG222 - Week 4 Medical Necessity Assessment (1)finished

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Bryant & Stratton College *

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222

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Mechanical Engineering

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Feb 20, 2024

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docx

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MCCG222 - Advanced CPT and HCPCS Level II Coding Week 4 Medical Necessity Assessment This Assessment is worth 15% of your overall grade. Deadline Due by the end of Week 4 at 11:59 pm, ET. (Saturday, 2/3/2024 @ 11:59 PM ET) Completing this Assessment will help you to meet the following: Course Outcome  Validate medical necessity for appropriate relationships between diagnosis and coded procedures/services. Directions Coders need to ensure medical necessity is met while coding. Insurance companies will deny payment if the codes do not support medical necessity. It is also not uncommon for insurance companies to vary in what one plan may cover and deem medically necessary. For this Assessment, you will review two patient cases and validate that the code assignments made by the encoder meet medical necessity. To begin, log into AHIMA VLab. Then follow the directions for each case below. Outpatient Surgery Case - Patient Number 311178 1. Review the Outpatient Surgery Case 311178 in AHIMA VLab, which can be found in Authentic Patient Cases. 2. After reviewing this case, review the code assignments that were made by the encoder in the table below. Code Assignment Code Description Principal Diagnosis J353 Hypertrophy of tonsils with hypertrophy of adenoids Principal Procedure 42820 Tonsillectomy and adenoidectomy; younger than 12 3. After you have reviewed the code assignments, review the Insurance Clinical Indications PDF for the procedures performed, which is provided in Blackboard.

MCCG222 – Medical Necessity Assessment 2 4. Now determine whether or not the diagnosis/diagnoses show medical necessity for the procedures performed. Explain your answer in detail in the box below. (25 points) Outpatient Clinic Case - Patient Number 410057 1. Review the Outpatient Clinic Case 410057 in AHIMA VLab, which can be found in Authentic Patient Cases. 2. After reviewing this case, review the code assignments that were made by the encoder in the table below. Principal Procedure: The diagnosis shows medical necessity to the procedures performed. The main reason as stated in the manual shows that the condition might be related to sleep-disordered breathing which if ignored can end up being chronic as the child turns into adulthood. The suggery procedure may also be made as per other symprtoms such as recurrent throat infections. If the procedure is performed, the child’s quality of life and health status will not be affected. The principal procedure is CPT 42820 for a Tonsillectomy and adenoidectomy; younger than 12. After reviewing the Clinical UM guidelines PDF, this procedure meets medical necessity. The diagnosis code is J35.3 and it would fall in between J35.01-J35.9 for Chronic diseases of tonsils and adenoids.

MCCG222 – Medical Necessity Assessment 3 Code Assignment Code Description Admitting Diagnosis C50.312 Malignant neoplasm of lower-inner quadrant of left female breast Secondary Diagnosis or Diagnoses Z171 Estrogen Receptor negative status Principal Procedure 19301-RT Partial Mastectomy Secondary Procedure 19285-RT Placement of breast localization device, percutaneous; first lesion, including ultrasound guidance (RT- Right side of the body) Third Procedure 14301 Adjustment tissue transfer/rearrangeme nt 3. Now determine whether or not the diagnosis/diagnoses show medical necessity for the procedures performed. Explain your answers in detail in the boxes below. (25 points each) Principal Procedure: Yes this is medical necessity this procedure is where the margins are indicated for the procedure. Third Procedure:Yes this is explaining the range of the procedure. Secondary Procedure: Yes This is determining where the pkacement if the device should be included guidance through ultra sound.

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