MCCG212 - Week 6 Medical Necessity Scenarios (1)

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Bryant & Stratton College *

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212

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Mechanical Engineering

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Dec 6, 2023

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MCCG212 – Advanced ICD Diagnostic Coding Week 6 Medical Necessity Scenarios This Assessment is part of the Case Scenarios category, worth 20% of your grade. Deadline Due by the end of Week 6 at 11:59 pm, ET. Completing this Assessment will help you to meet the following: Course Outcomes  Validate medical necessity for appropriate relationships between diagnosis and healthcare services.  Abstract and apply the advanced ICD-10-CM classification requirements to fulfill the official coding guidelines. Directions ICD-10-CM codes should support medical necessity for any services reported by a provider. Diagnosis codes identify the medical necessity of the services by describing the patient’s condition and establishing that the service provided is reasonable and necessary. Using your ICD-10-CM codebook, apply the proper codes for scenarios 1 and 2. For scenario 1, using your ICD-10-CM codebook and the skills you have learned regarding medical necessity, code the scenario and answer the following question: “Has medical necessity been met?” Justify your reasoning. 1. Amy is visiting her gynecologist today for an annual visit. Amy would also like to discuss with her provider the concerns she has regarding very painful cramping during the time of her period as well as an abnormally heavy flow. Amy feels weak at times and worries that she may pass out while working. Amy’s gynecologist orders an abdominal ultrasound and asks Amy to come back during her next period for lab work to check her iron levels. What diagnosis codes(s) should the coder report for Amy’s visit? -N94.6 for dysmenorrhea, unspecified. This code is used to indicate painful menstrual cramps that are not caused by a specific condition. -R25.2 for cramp and spasm. This code is used to indicate abnormal involuntary muscle contractions that may occur during dysmenorrhea.

MCCG212 – Medical Necessity Scenarios 2 *Medical necessity has been met; the doctor looked into her symptoms and order more tests for when the right time to see results would be best. For scenario 2, code the cases based on Official Coding guidelines. In addition, remember that each service should be linked to a diagnosis to establish medical necessity. 2. Tina is a 60-year-old female who has arrived at the urgent care clinic because she fell down her porch steps while chasing after her dog. She is complaining of pain in her left ankle and lower calf. Tina also explains to the provider that she has type 1 diabetes, and it is now the time of day when she regularly checks her blood sugar. The physician orders an x-ray of Tina’s left lower leg and a random blood sugar test. What diagnosis code(s) should the urgent care coder report for Tina’s visit? -S82.62XA for fracture of lateral malleolus of left fibula, initial encounter for closed fracture1. This code is used to indicate the injury to Tina’s left ankle and lower calf caused by the fall. -W10.9XXA for fall (on) (from) stairs and steps, initial encounter2. This code is used to indicate the external cause of Tina’s injury. -E10.9 for type 1 diabetes mellitus without complications3. This code is used to indicate Tina’s chronic condition that requires blood sugar monitoring. The coder should also link each service to a diagnosis to establish medical necessity, the x-ray of Tina’s left lower leg should be associated with S82.62XA and W10.9XXA. The random blood sugar test should be connected to E10.9. Scenarios 3 and 4 have been coded for you. Based on what you have learned about medical necessity, evaluate the codes provided and answer the following question: “Is medical necessity met?” Justify your thinking. 3. Annmarie is an auditor in Dr. Jacob’s office. After reviewing some of Dr. Jacob’s patient records, Annmarie notices that Dr. Jacob’s has been ordering Prostate Specific Antigen (PSA) lab work for every male patient over the age of 50. Annmarie sits down with Dr. Jacob to let him know that he should not be ordering the same test for every patient. Dr. Jacob explains to Annmarie that none of the patients who he ordered a PSA check have had one done in the last year and that medical necessity has been met. In this case, who is correct? Explain your reasoning. -Based on medical necessity, Annmarie is the correct one. Dr. Jacobs should not be ordering PSAs for every male over the age of 50 unless they have

MCCG212 – Medical Necessity Scenarios 3 other risks or prostate cancer. Ordering these tests lead to false positives, overdiagnosis, and increased cost. 4. Karen has been suffering with back pain for the past 2 years. She has tried different office chairs at work, yoga classes, a back brace, and has even purchased a new mattress. Nothing she has tried is providing any relief. Karen had an appointment with an orthopedic specialist today who has decided to move forward with a spinal nerve ablation in her lower lumbar and sacral area. Based on the information provided, has medical necessity for the spinal nerve ablation been met? Justify your reasoning. -With this scenario, I do not think medical necessity has been met. The reason is the doctor doesn’t have a diagnosis written. Spinal nerve ablation, also known as radiofrequency ablation, needs more details on why it is recommended. This doctor would need to give a specific reason why he wants to go this route. With research as well, it is said that RFA is not effective in all cases of spinal pain. So this could possibly not work at all.

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MCCG212 – Medical Necessity Scenarios 4 MCCG212 – Medical Necessity Scenarios Grading Rubric Criteria Exceeds Expectations Meets Expectations Needs Improvement Points Accuracy of Codes Assigned 40 points 36-40 points All the codes assigned are accurate. All codes have been assigned. No extra codes are listed. 16-35 points Most of the codes assigned are accurate. Most codes have been assigned. A few extra codes are listed. 0-15 points Less than half of codes assigned to scenarios are accurate. Many codes have not been assigned. Numerous extra codes are listed. Rationale 40 points 36-40 points Detailed rationale statements are provided. Rationale is thorough and accurate, including specific references to the case. 16-35 points General rationale statements are provided. Rationale lacks some detail or includes a few minor errors. 0-15 points Rationale statements are not provided. Rationale is inaccurate or significantly lacking detail. Overall 20 points 18-20 points Clearly demonstrates successful understanding of assigning ICD-10- CM diagnosis codes as well as determining medical necessity. Expectations have been exceeded. 6-17 points Demonstrates successful understanding of assigning ICD- 10-CM diagnosis codes as well as determining medical necessity. Expectations have been met. 0-5 points Improvement needed regarding the understanding of medical necessity. Expectations have not been met. Instructor Comments: Total Points: