Week 6- Medical Necessity Assignment
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School
Bryant and Stratton College, Buffalo *
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Course
MCCG 136
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by CaptainBoulder12875
Medical Necessity Assignment
Scenario 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 code(s) should the coder report for
Amy’s visit?
The codes that I have chosen for this scenario are Z01.419, Encounter for gynecological
examination without abnormal findings and N94.6, Dysmenorrhea, unspecified as well as R53.1
generalized weakness. I chose these three codes because for the first, there was no documentation
leading me to any abnormal findings, the patient is complaining of painful cramping which is indicative of
dysmenorrhea. I feel that medical necessity has been met with the ordering of the labs and ultrasound
since there is a need to see what is happening internally and if the blood work will direct to a diagnosis
as cause of the weakness.
Scenario 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 ordered 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?
The codes
that I have selected are WI3.0XXA, fall from, out of, or through balcony, initial encounter and Y93.K,
activities involving animal care. I also coded M79.6, left lower leg pain and with the excludes 2 notation, I
also coded M25.5, pain in joint. The x-ray is medically necessary due to needing to determine the cause
of the pain, and I feel that the blood sugar test is necessary to rule out whether a low/high blood sugar
could have contributed to the fall.
Scenario 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.
Annmarie is correct in this
scenario because there isn’t a recommendation of annual PSA labs to be drawn annually on any man
over 50 according to a few online resources.
Scenario 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.
It is not medically necessary to perform a spinal nerve ablation on Karen yet. The reason that
it is not necessary is because all other measures for relief have not been exhausted. There is no mention
of PT or medications being attempted in the past.
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