MCCG 146 Week 7 LCD NCD Assignment

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Bryant & Stratton College *

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146

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Mechanical Engineering

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Dec 6, 2023

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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: L4397 LCD/LCA Article ID: L33686 State: Indiana Is this covered or non-covered? Yes Rationale: This should be covered as the provider is the one ordering this and the patient has been diagnosed with the plantar fasciitis criterion 5 was met.

MCCG146 – LCD/NCD Assignment 2 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: A53026 State: California Is this covered or non-covered? No Rationale: This would not be covered as the patient is refusing to comply with physician’s advice/treatments previously to loose the weight. She is also smoking still which is something that could vastly complicate her recovery from the procedure it’s a high risk that she would take on her own. 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? No Rationale: The patient has no indications medically that the skin lesion needs to be removed she simply does not like the way it looks. This would be considered cosmetic making it not covered. 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 20561 LCD/LCA Article ID: L35010 State: Colorado NCD Manual Section Number (s) 30.3

MCCG146 – LCD/NCD Assignment 3 Referenced Is this covered or non-covered? No Rationale: This would not be covered due to acupuncture only being covered if performed for chronic low back pain not lower extremities where she has expressed her pain. Scenario 5 Patient needs to have treatment of their kidney stones and is scheduled to have a Nephrolithotomy to remove the kidney stones. CPT code for Treatment of Kidney Stones - Nephrolithotomy: 50060 NCD Manual Section Number: 230.1 Is this covered or non-covered? Yes Rationale: The NCD states percutaneous lithotripsy (nephrolithotomy) is covered under Medicare standards.

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MCCG146 – LCD/NCD Assignment 4 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: