MCCG212 - Week 4 Medical Necessity Scenarios - Jodi Camp

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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 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? Answer: Other fatigue- R53.83 Abnormal weight gain- R63.5 Pain in unspecified joint- M25.50 Menopausal and female climacteric states -Z78.0 The provider is checking Joan’s blood to determine the cause of her symptoms. Joan’s symptoms of fatigue, weight gain, and joint pain may indicate a thyroid dysfunction or because of her hot flashes this could indicate a possible hormonal inbalance. It is reasonable and necessary for the provider to order these tests, therefore medical necessity has been met in this case. 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 fever. The urgent care provider performed a urinalysis and strep throat swab. What diagnosis code(s) should the coder report for Luisa’s visit? Answer: Painful micturition, unspecified – R30.9 Acute pharyngitis, unspecified- J02.9 Fever, unspecified – R50.9

MCCG212 – Medical Necessity Scenarios 2 By reporting these codes, this would show that medical necessity is established in this case in order to determine if the patient has strep throat or possible UTI. 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. ANSWER: Jonathan has failed all forms of treatment suggested by his physician. Jonathan is still having severe knee pain from his osteoarthritis despite the use of NSAIDS, physical therapy, and steroid injections. In this case Jonathan has exhausted all of his options and I believe that the code M17.11 for osteoarthritis of the right knee will support and meet the medical necessity in order for surgery to be approved. 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. ANSWER:

MCCG212 – Medical Necessity Scenarios 3 Due to these injections that are very costly, patients must attempt all effective and less costly methods before advancing to this type of treatment. Amanda refused phototherapy that was recommended by her dermatologist and is not willing to try any other treatments, therefore the insurance company is going to come back and state that code L30.9 for eczema for authorization of Dupixent does not meet medical necessity so her claim will not be reimbursed for the Dupixent medication treatment due to Amanda is not willing to try more cost-efficient treatments.

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MCCG212 – Medical Necessity Scenarios 4 dMCCG212 – 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: