MCCG146 - Portfolio Project Coding
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School
Bryant & Stratton College *
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Course
MCCG146012
Subject
Medicine
Date
Jan 9, 2024
Type
docx
Pages
4
Uploaded by MajorSparrowPerson922
Rebecca McMullen
November 15, 2023
Portfolio Project
Week 3: Jane Smith’s Physician Office Visit
Provide CPT Evaluation and
Management (E/M) Code:
The CPT E/M code for this case would be
99214. This is used for office or outpatient
visits for evaluation and management of an
established patient. These visits consist of
medically appropriate history and examination
with a moderate level of medical decision-
making.
Reflection/Method on Code Selection –
Describe in detail the steps/method
you took to code the services correctly
and to ensure the services are coded
correctly.
The setting for this case takes place in an
office setting, which narrows down the codes
to use to 99201-99215. As stated, Jane Smith is
an established patient, her history was detailed
with the review of pathology, mammograms,
and previous notes. She was also given a very
detailed and appropriate medical examination.
After this the physician discussed in detail
Jane’s options on next steps and other
treatment options. This included surgery, a
PET and CT scan, as well as a referral to a
plastic surgeon and therapist, which indicates a
high level of medical decision-making. When
ensuring the correct code was chosen you
should first review all documentation that was
provided, this is to make sure it supports the
code. For Jane Smith’s case, the
documentation supports the code 99215.
Staying updated on coding guidelines from
AMA and CMS can help keep you updated on
any annual changes. Asking questions can also
help when choosing the proper code, if you are
unsure of any information asking the providing
physician can clear up any questions.
Week 4: Jane Smith’s Imaging Services
MCCG146 – Portfolio Project Coding Template
2
Provide CPT Code(s) and modifier if
applicable for the professional
component provided for the Imaging
Services:
78815
Provide the HCPCS Code(s) for the
Radiopharmaceutical Agent Injected
during Imaging Procedure:
A9552
Using Medicare’s website,
https://www.cms.gov/medicare-
coverage-database/search.aspx
determine whether or not the CPT
code has an active LCD and Answer
the following question: - Does the
Imaging Procedure CPT code you
selected have an active Article/LCD?
Yes/No?
If yes, Identify Article/LCD.
Article: A57807
Title: Billing and Coding: Independent
diagnostic testing facilities (IDTF)
Original date: 10/01/2018
Revision date: 10/01/2023
Reflection/Method on the Code
Selection.
Describe in detail the
steps/method you took to code the
services correctly and to ensure that
the services are coded correctly.
When choosing CPT code 78815 I went to the
index and looked under the sections of positron
emission tomography (PET). From there I
looked until I found from the skull base to mid-
thigh as that was what was stated in the
physician’s documentation. I then found the
code on page 569 and went through each code
while following the doctor's notes as it was
ordered. A CT scan was also done on Jane
Smith, but because it was done for attention
correction and anatomical localizing it did not
need the modifier 59 added onto it.
Week 5: Jane Smith’s Pre-Op Lab (Report 1) and Outpatient Surgery
(Report 2)
MCCG146 – Portfolio Project Coding Template
3
Provide CPT Code (s) for Pre-Op Lab
Orders (Report 1)
93005 – EKG
85025 – CBC with platelet
87635 – COVID Screening
85014 – Hematocrit
80053 – Comprehensive metabolic
panel
Provide the CPT Lab Codes that have a
CCI Code Pair Edit (PTP) and include
the CCI PTP associated modifier.
85025
85014
Provide CPT Code(s) for Surgeon’s
Outpatient Surgery Services and
modifier if applicable (Report 2):
19307-50
Reflection/Method on the Code
Selection. Describe in detail the
steps/method you took to code
services and to ensure the services are
coded correctly.
For each code I chose I went through
the index. I looked up each main
term for the labs ordered, then
followed the code to make sure it
met all requirements. For the
mastectomy, I looked under radical,
there I went through each code along
with the documentation provided to
make sure it matched the
documentation. As stated in the book
it says to report bilateral procedures
for 19300-19307, report modifier 50
with the procedure code.
Week 6: Jane Smith’s Inpatient Consultation with Procedure
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MCCG146 – Portfolio Project Coding Template
4
Provide CPT Evaluation and
Management (E/M) Code:
99283
Provide CPT Procedure Code for
Procedure (s) and modifier if
applicable:
93000
Reflection/Method on Code Selection.
Describe in detail the steps/method
you took to code the services and to
ensure the services are coded
correctly.
For code 99283, I chose this because
as stated Jnae went into the
emergency department, was
evaluated and a medically
appropriate evaluation and history
was done with a low level of medical
decision making. When choosing the
code 93000 I looked up ECG in the
alphabetic index and under routine,
minimum 12-lead went to code 9300.
There I went to page 757 and
decided this code was the best
choice as it matched the
documentation provided.