MCCG222 - Portfolio Project Coding Template - Jodi Camp
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MCCG222 – Advanced CPT and HCPCS Level II Coding Portfolio Project Coding Template
Week 2: Rodney Balbo’s Emergency Room Visit ICD-10-CM Code(s):
S01.01XA; W18.2XXA; Y92.012; R51.9
CPT Code(s): 12002
HCPCS Level II Code(s):
N/A
Reflection:
The patient in this scenario fell in his bathroom. He hit his head on the edge of the bathtub, and he now has a headache. He also has a 3cm laceration on the left side of his scalp. He does not know how he fell or what caused him to fall. He was given Tylenol for the pain. The laceration was repaired with sutures. The patient was instructed to follow-up with his primary care physician.
I coded the following scenario by first looking up ICD-10-CM code for Laceration, scalp, initial encounter and found code S01.01XA
. I then looked
up the external cause of the injury. I looked under the tabular cause of injury and looked up fall as the main term, and then in, on as the subterm, and then bathtub. After reviewing the tabular. It requires 7 characters, and since this is an external cause code, the 7th character will be an A, D, or S. A would be selected in this instance since this is an initial encounter, the final code for external cause of injury would be (W18.2XXA)
. I coded the scenario further by finding the location of the fall by looking under place of occurrence, which was his home or residence, private (Y92.012)
, In the ICD-10-CM Codebook, I went to the External Cause Index. I chose Place of Occurrence as the main term, then house, then bathroom. After reviewing the tabular: no additional characters or instructional notes. I also coded R51.9 for his headache. I then went on to code for the CPT code, procedure
of Laceration Repair by coding 12002 which is for simple repair of superficial wound of scalp 2.6cm to 7.5cm. Notably, no indication warranted the utilization of HCPCS Level II coding in this particular instance.
Week 3: Rodney Balbo’s Office Visit
MCCG222 – Portfolio Project Coding Template 2
ICD-10-CM Code(s):
G44.309; R40.0; I10; W18.2XXA
0.0CPT Code(s): 99213
HCPCS Level II Code(s):
N/A
Reflection:
Rodney Balbo is an established patient with a history of hypertension that was seen in the office today for a lingering headache and drowsiness that he has had after he fell and hit his head two days ago. He was seen in the ED two days ago and treated for a scalp laceration. The ICD-10-CM code G44.309
- post-traumatic headache, unspecified, not intractable is used to represent the patient's headache due to his fall. The ICD-10-CM code R40.0
- Somnolence, stupor and coma is used to account for the drowsiness
that has developed over the last two days. The code I10
- Essential hypertension, is used to represent the patient's hypertension that is now controlled with medication. The code W18.2XXA
- Fall into shower or empty bathtub, initial encounter is used to represent the patients fall into the bathtub. The CPT code 99213
- Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making, is used to account for the time the provider spent examining the patient. To find the correct E/M code by level of medical decision making, the doctor is evaluating 1 acute, uncomplicated injury that required him to order a unique test and carries a low risk of morbidity from additional diagnostic testing or treatment. This would make the MDM level of low and code 99213 and uses total time on the date of encounter of 20 minutes. There is no relevant HCPCS Level II Code for this encounter.
Week 4: Rodney Balbo’s Imaging Service
ICD-10-CM Code(s):
CPT Code(s):
HCPCS Level II Code(s):
LCD Article ID Number: Reflection:
Week 5: Rodney Balbo’s Outpatient Surgery #1
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