1714024768_1713515837_MCCG222PortfolioProjectCodingTemplatecomplete_1

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Apr 30, 2024

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General Business General Business 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): R51.9, I10, S01.01XA, W18.2XXA, Y92.012 CPT Code(s): 12002, 99282 HCPCS Level II Code(s): NA To code this medical case, I conducted research on Laceration and Scalp using the ICD-10-CM Index. Based on my findings, I suggest using S01.01XA code for Laceration without a foreign body of the scalp for the initial encounter and W18.2XXA code for the place of occurrence, which is a single-family home bathroom with a Y92.012 code. For CPT codes, I recommend 99282 for an Emergency Room visit that is straightforward and 12002 for a Simple Repair of the scalp that measures between 2.6-7.5 cm. Week 3: Rodney Balbo’s Office Visit ICD-10-CM Code(s): G44.309, R40.0, W18.30XA ,I10 CPT Code(s): 99213 HCPCS Level II Code(s): Reflection: To determine the necessary codes for the patient's visit, I referred to my ICD-10 index and located the appropriate codes for their symptoms, including post-traumatic headache (G44.309), dizziness (R40.0), and unspecified fall as an external cause (W18.30XA). Additionally, I included code I10 to account for the patient's current hypertension. For the established patient visit, I utilized CPT code 99213, which allows for a 20-minute face-to-face consultation. As a professional in this field, I am well-versed in the various office visit codes and their corresponding time and decision-making requirements, which I utilize regularly in my work.
General Business General Business Week 4 Rodney Balbo’s Imaging Service ICD-10-CM Code(s): G44.309, R40.0 CPT Code(s): 70552 HCPCS Level II Code(s): A9585 LCD Article ID Number: A57204 Reflection: To determine the appropriate procedure, I consulted the patient's medical history and noted a diagnosis of post-traumatic headache and drowsiness. Using my ICD-10 Codebook, I looked up relevant codes previously used for this patient. I then referred to my CPT book on Diagnostic Radiology for Head and Neck to identify the appropriate MRI procedure with contrast. After identifying the correct procedure, I confirmed the necessary HCCPS code for the contrast agent Gadavist by looking under the Table of Drugs in the HCPCS book. I then consulted the CMS LCD on the internet to ensure medical necessity for the procedure. Upon confirming the diagnosis code was listed under the necessary dx codes, I determined that the MRI would be considered medically necessary.
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