MCCG212 - Week 4 Medical Necessity Scenarios

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Bryant & Stratton College *

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212

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Mechanical Engineering

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Apr 3, 2024

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MCCG212 – Advanced ICD Diagnostic Coding Week 4 Medical Necessity Scenarios This Assessment is part of the Case Scenarios category, worth 20% of your grade. Deadline Due by the end of Week 4 at 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 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. Follow the instructions below for the following scenarios. 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. Joan is a 64-year-old woman who is visiting her primary care provider today for increasing fatigue, weight gain, and joint pain. Joan is sent to the lab for thyroid function tests to measure her thyroid hormone levels. Additionally, Joan’s doctor would like to have her follicle stimulating hormone (FSH) and estrogen measured to determine the cause of her hot flashes. What diagnosis code(s) should the coder report for Joan’s visit? 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. Luisa is visiting the urgent care clinic today because she has been having burning with urination for the past day or so. In addition, Luisa noticed last night that her throat was getting sore, and she was running a low-grade

MCCG212 – Medical Necessity Scenarios 2 fever. The urgent care provider performed a urinalysis and strep throat swab. What diagnosis code(s) should the coder report for Luisa’s visit? Scenarios 3 and 4 have been coded for you. Based on what you have learned about medical necessity, evaluate the codes provided to answer the following question: “Has medical necessity been met?” Justify your reasoning. 3. Jonathan is a 67-year-old male with a history of osteoarthritis in his right knee. Lately, Jonathan’s pain has become so severe that he is no longer able to climb the stairs in his home. For the past year, Jonathan’s doctor has tried multiple treatments such as NSAIDS, physical therapy, and steroid injections. Jonathan has confirmed that although treatments are helping at first, nothing is providing lasting relief. The risks and benefits of a right total knee arthroplasty was performed, and pre-operative appointments were scheduled. The coder reviewing this case coded M17.11 for osteoarthritis of the right knee. Does this diagnosis meet medical necessity for a right total knee arthroplasty? Explain your reasoning. 4. Amanda is a 15-year-old female who has been suffering for the past year with severe eczema. Amanda’s dermatologist recommended that she begin phototherapy since topical medications have not been effective. Amanda’s friend has been using Dupixent in the form of biweekly injection. Amanda would prefer the injection and declines her doctor’s suggestion to begin phototherapy. The code L30.9 for eczema has been sent to Amanda’s insurance company for authorization of Dupixent. Does Amanda’s case meet medical necessity for the injection? Justify your response.

MCCG212 – Medical Necessity Scenarios 3 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:

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