MCCG146-PortfolioProjectCodingWeek6-ShannonHutsonagain

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Feb 20, 2024

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MCCG146 – CPT and HCPCS Level II Coding Portfolio Project Coding Template Module 3: Jane Smith’s Physician Office Visit CPT E/M Code(s): Reflection/Method on Code Selection – Describe in detail the steps/method you have taken to ensure you have coded this patient encounter properly 99215- Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When deciding on choosing the code 99215, I used the MDM Table to find that the patient qualified as a high level of medical decision making based on the physician’s notes. The patient was being seen for a follow up of recurrent diagnosis carcinoma of the left breast. The complexity of her problem addressed at the encounter would be high based on it being a chronic illness with progression that poses a threat to life or bodily function. The amount and or complexity of data to be reviewed or analyzed met the extensive Category 1 by reviewing 2 tests, ordering a unique test (CT PET), and 2 follow-ups with a plastic surgeon, and therapist. Risk of complications and/or morbidity or mortality of patient management was met discussion in detail for the options including the decision for surgery. This is what lead me to decide that 99215 was the code that was to the highest level of specificity based on the physician’s notes. Module 4: Jane Smith’s Imaging Services

CPT Code(s) for Imaging Services: 78815 HCPCS Code(s) for Injection Agent: A9552 Using Medicare’s website, determine whether or not the CPT has an active LCD or LCA based on the CPT Imaging code assignment. Does the Imaging Procedure CPT code you selected have an active LCA/LCD? Identify Article. The code has an active LCD in Virginia. I used Virginia because I could not find a state listed on the patient’s records. It has a retired LCD in Virginia. It is considered to be priced under one methodology and not covered. Reflection/Method on Code SelectionDescribe in detail the steps you have taken to ensure you have coded this patient encounter properly 78115 - Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh. To find this code, I looked up positron emission tomography in the CPT index. Scrolling down to with computed tomography (CT)…. 78814, 78815. I then looked up 78814 in the Radiology section of the manual and found that the code 78815 was the most accurate code to use. A9552 - Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries. I could not figure out how to access the HCPCS II in the school library. I found the HCPCS website and looked up fluorodeoxyglucose injection and was given code A9952 and S8085, which I further researched to find that S8085 is a temporary code with little information available. However code A9952, had lot’s of information that indicated it to be the right code to use. When checking for an active LCD, I did find that it was retired because it was considered a part of a bundle that would be billed with the PET scan. I have ordered a HCPCS manual that I will use for future coding.

Module 5: Jane Smith’s Pre-Op Lab and EKG and Outpatient Surgery

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