Shareese Hill
MCCG222 WEEK 5 PORTFOLIO
Rodney Balbo’s Outpatient Surgery #1 Overall, the approach I used to determine the codes for Rodney Balbo was comprehensive and precise. By adhering to the previously outlined steps, I am assured that all coding has been done correctly and that the information provided for this patient's imaging service is accurate.
ICD-10-CM Code(s):
G44.309, R40.0
CPT Code(s):
70552
HCPCS Level II
Code(s):
A9585
APC:
A57204
Reflection: The appropriate codes have been assigned. For the diagnosis of post-traumatic headache and drowsiness, the ICD-
10-CM codes are G44.309 and R40.0, respectively. These codes were selected because G44.309 represents post-traumatic headache and R40.0 signifies drowsiness in the ICD-10 classification. The CPT code for an MRI of the brain with contrast is 70552. The HCPCS Level II code is required for the gadolinium-based contrast agent (GBCA). To ascertain if the CPT code has an active Local Coverage Determination (LCD), I navigated to Medicare's website and conducted a search for CPT code 70552. My search revealed an active LCD for this code, with the LCD Article ID Number being A57204.
To ensure accurate coding, I followed several steps. Initially, I meticulously reviewed the Imaging Service Note to verify that I possessed all the required information. Subsequently, I researched the correct codes for the diagnosis, procedure, and contrast material using authoritative sources like the ICD-10-CM, AMA CPT, and CMS' HCPCS Level II codebooks. I then reconfirmed the accuracy and currency of the codes I selected. Afterward, I searched for any applicable guidelines and found none. Lastly, I validated the LCD Article ID Number by checking it against the information on Medicare's website. Overall, the approach I used to determine the codes for Rodney Balbo was comprehensive and precise. By adhering to the previously outlined steps, I am assured that all coding has been done correctly and that the information provided for this patient's imaging service is
