CORRECTION_MCCG146 - Week 7 LCD NCD Assignment

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Bryant & Stratton College *

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JMCCG13701

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Mechanical Engineering

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Feb 20, 2024

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MCCG146 – CPT and HCPCS Level II Coding Week 7 LCD/ NCD Assignment This Assessment is worth 10% of your grade. Deadline Due by the end of Week 7 at 11:59 pm, ET. Completing this Assessment will help you to meet the following: Course Outcome  Validate medical necessity using LCD and NCD in provided scenarios. Directions 1. Review the five scenarios below and assign the appropriate HCPCS Level II or CPT code. 2. Visit the Medicare Coverage Database to find and assign the Local Coverage Determination (LCD) /Local Coverage Article (LCA) Article ID or National Coverage Determination (NCD) Manual Section Number associated with the assigned HCPCS Level II or CPT code. After reviewing the LCD/LCA/NCD, determine if the documented service is covered under the determination. Provide rationale as to whether or not the HCPCS Level II or CPT code is covered for the documented reason and if this will meet medical necessity based on the LCD/NCD. Scenario 1 Patient has been recently diagnosed with plantar fasciitis. The provider orders a static foot orthosis. HCPCS Level II code for static foot orthosis, prefabricated, customized for patient: L4396 LCD/LCA Article ID: L33686 State: Indiana Is this covered or non-covered? Covered Rationale: An L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 - 4 or criterion 5 is met: 1. Plantar flexion contracture of the ankle (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and,

MCCG146 – LCD/NCD Assignment 2 2. Reasonable expectation of the ability to correct the contracture; and, 3. Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities; and, 4. Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons. 5. The beneficiary has plantar fasciitis (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses). The patient has plantar fasciitis, so it is covered. Scenario 2 Morbid obese patient is scheduled to have a laparoscopic sleeve gastrectomy. The patient has been non-compliant with other forms of medical treatment to lose weight, has been diagnosed with bipolar disease, and refuses to quit smoking cigarettes. CPT code for laparoscopic sleeve gastrectomy: 43775 LCD/LCA Article ID: 100.1 State: California Is this covered or non-covered? Non-covered Rationale: The following bariatric surgery procedures are non-covered for all Medicare beneficiaries: Open adjustable gastric banding; Open sleeve gastrectomy; Laparoscopic sleeve gastrectomy (prior to June 27, 2012); Open and laparoscopic vertical banded gastroplasty; Intestinal bypass surgery; and, Gastric balloon for treatment of obesity.

MCCG146 – LCD/NCD Assignment 3 Scenario 3 Patient has a 0.9 cm benign skin lesion located on her forearm. She does not like the appearance of it and requested it to be removed. When the provider asked about the associated symptoms, the patient indicated that there were none; she just does not like the appearance. CPT code for removal of 0.9 cm benign skin lesion on forearm, simple repair: 11401 LCD/LCA Article ID: A57482 State: Indiana Is this covered or non-covered? Non-covered Rationale: It is seen as a cosmetic surgery. In the absence of signs, symptoms, illness or injury, Z41.1, encounter for cosmetic surgery, should be reported, and payment will be denied. (Ref. CMS Pub.100-04 Medicare Claims Processing Manual , Ch. 23 §§10.1-10.1.7) Scenario 4 Patient has had fibromyalgia for 2 years. She is requesting trigger point injections of her knotted muscles in her legs (sartorius, semimembranosus, semitendinosus and gastrocnemius) as that is where she experiences most of her pain. CPT code for Trigger Point Injections 20553 LCD/LCA Article ID: A57751 State: Colorado NCD Manual Section Number (s) Referenced 150.7 Is this covered or non-covered? Covered Rationale: Because the patient has fibromyalgia, it is covered It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. The following ICD-10 CM codes support medical necessity and provide coverage for CPT/HCPCS codes 20552 and 20553: Scenario 5 Patient needs to have treatment of their kidney stones and is scheduled to have a Nephrolithotomy to remove the kidney stones.

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MCCG146 – LCD/NCD Assignment 4 CPT code for Treatment of Kidney Stones - Nephrolithotomy: 50060 NCD Manual Section Number: 230.1 Is this covered or non-covered? Covered Rationale: In addition to the traditional surgical/endoscopic techniques for the treatment of kidney stones, the following lithotripsy techniques are also covered for services rendered on or after March l5, l985. B. Percutaneous Lithotripsy Percutaneous lithotripsy (or nephrolithotomy) is an invasive method of treating kidney stones by using ultrasound, electrohydraulic or mechanical lithotripsy. A probe is inserted through an incision in the skin directly over the kidney and applied to the stone. A form of lithotripsy is then used to fragment the stone. Mechanical or electrohydraulic lithotripsy may be used as an alternative or adjunct to ultrasonic lithotripsy. Percutaneous lithotripsy of kidney stones by ultrasound or by the related techniques of electrohydraulic or mechanical lithotripsy is covered under Medicare. The following is covered for services rendered on or after January 16, 1988.

MCCG146 – LCD/NCD Assignment 5 MCCG146 – LCD/ NCD Assignment Grading Rubric Criteria Exceeds Expectations Meets Expectations Needs Improvement Points CPT/ HCPCS Level II Code Identificatio n (50 points) 50 points 5/5 of the CPT/HCPCS Level II codes were identified accurately. 40 - 49 points 3-4 of the CPT/HCPCS Level II codes were identified correctly. 0 - 39 points 2 or fewer of the CPT/HCPCS Level II codes were identified correctly. LCD/LCA/NCD Identificatio n (20 points) 20 points 5/5 of the LCD/LCA/NCDs were identified accurately. 15 - 19 points 3-4 of the LCD/LCA/NCDs were identified accurately. 0 - 14 points 2 or fewer of the LCD/LCA/NCDs were identified accurately. Rationale (30 points) 30 points The rationale provided is thorough and the explanation of 5/5 scenarios is accurate. 20 - 29 points The rationale provided is thorough and the explanation of at least 3-4 of the scenarios is accurate. 0 - 19 points The rationale provided is thorough and the explanation of 2 or fewer of the scenarios is accurate. Instructor Comments: Total Points: