Scenario 1
A patient presents with right upper quadrant pain, nausea and vomiting. The physician examines the patient, completes an abdominal ultrasound of the right upper quadrant. Examination and ultrasound show calculi in the gall bladder. The doctor diagnosis the patient with cholecystitis. The physician determines that the patient will need to have a Cholecystectomy. The procedure is scheduled.
1. Are the signs and symptoms presented
consistent with the providers diagnosis? What coding classification system
would be used to assign a diagnosis?
The provider’s diagnosis of cholecystitis is
consistent with a patient presenting with pain in the upper right quadrant with
nausea and vomiting for symptoms. The diagnosis of cholecystitis was confirmed
by abdominal ultrasound imaging and would be coded using the ICD-10-CM
classification system.
2. Explain what procedures were
performed to prove this diagnosis? What coding classification system would be
used to assign a code for the procedure(s) performed?
The
procedures performed to prove this diagnosis included physical examination and evaluation
of presenting symptoms performed by the provider which would be coded with an Evaluation
and Management (CPT) code and a Laboratory (CPT) code for the abdominal
ultrasound imaging that shows calculi in the gall bladder.
3. Explain the importance of accurately
linking the correct diagnosis and procedure codes to achieve medical necessity.
Was medical necessity met in this scenario? Why or why not?
The importance of accurately linking the correct diagnosis and procedure codes to achieve medical necessity is that the diagnosis will usually be the determining factor as to whether the services provided were medically necessary. Cholecystectomy Surgery is recommended for this diagnosis to avoid further complications or blockages of the gall bladder ducts and is performed in an inpatient setting which would be coded with an ICD-10-PCS code. Medicare national coverage determinations (NCDs) and local coverage determinations (LCDs) dictate which diagnosis codes must be documented by clinicians to support the medical necessity of most services or supplies they provide to patients. (Comstock, J., CPC, Two Medicare cases illustrate the importance of NCDs and LCDs, para1.) I don’t have enough information to confirm medical necessity by (NCD) or (LCD)
, I do not believe that the criteria for medically necessary services have been met because there is no documentation available to explain how the patient meets the explicit criteria developed by doctors to screen for appropriateness for Cholecystectomy surgery that has been scheduled. “In order to fulfill billing compliance regulations: the following documentation is required: (1) medical necessity; (2) image interpretation; and (3) image archive. Addressing each element specifically, the medical necessity for the utilization of ultrasound must be clearly recorded. According to the American College of Radiology guidelines, this requirement is fulfilled with documentation of relevant history (including known diagnoses) and signs and symptoms”. (radiologykey.com, para. 8.)
Scenario
2
A
patient presents with fever and a sore throat.
The patient states they have had a sore throat for 5 days. The physician
performs a rapid strep test that is negative.
The doctor diagnosis with patient with strep throat.
1. Are the signs and symptoms presented consistent with the provider’s diagnosis? What coding classification system would be used to assign a diagnosis?
A
patient presenting with a fever and a sore throat would be consistent with symptoms
for a diagnosis of strep throat. The code set for assigning the diagnosis for
strep throat would be ICD-10-CM.
2. Explain what procedures were
performed to prove this diagnosis? What coding classification system would be
used to assign a code for the procedure(s) performed?
Procedures
performed to prove this diagnosis would be discussing the patients symptoms,
checking for signs and symptoms present, then performing a rapid strep test and
when the results are negative, as they are in this scenario, if the provider
still believes it is strep throat, the provider will need to take a throat
culture swab to rule in the strep throat diagnosis. The coding classification
systems used to assign codes for the procedures performed are Evaluation and
Management and Laboratory CPT codes.
3. Explain the importance of accurately
linking the correct diagnosis and procedure codes to achieve medical necessity.
Was medical necessity met in this scenario? Why or why not?
The importance of accurately linking the correct diagnosis and procedure codes to achieve medical necessity is stressed to achieve the highest allowable reimbursement for services provided and for protection from malpractice and civil litigation of claims. I do not think the criteria for medical necessity was met in this scenario because the results of the first test performed were negative for strep throat and in order for the provider to rule in the diagnosis of strep throat, another procedure must be performed to determine whether it is strep throat and according to the notes available this was not done. The diagnosis was not confirmed and therefore is not accurate, does not meet criteria for medically necessary services and would not be appropriate to use for coding on a billable claim.
Scenario
3
A patient presents with a fever, a burning sensation when urinating and blood in the urine. The patient provides a urine sample to be tested and the physician orders a urinalysis and a urine culture. The result shows bacteria and an increased number of white blood cells in the urine. The physician diagnoses the patient with a urinary tract infection.
1. Are the signs and symptoms presented
consistent with the provider’s diagnosis? What coding classification system
would be used to assign a diagnosis?
Symptoms
of fever and a burning sensation when urinating and blood in the urine are
consistent with symptoms of a diagnosis for urinary tract infection. The coding
classification system used to assign the diagnosis would be ICD-10-CM.
2. Explain what procedures were
performed to prove this diagnosis? What coding classification system would be
used to assign a code for the procedure(s) performed?
Procedures
performed to prove the diagnosis of a urinary tract infection would be the
urinalysis and urine culture. The coding classification system that is used to
assign codes for the procedures performed are the Evaluation and Management and
Laboratory CPT codes.
3. Explain the importance of accurately
linking the correct diagnosis and procedure codes to achieve medical necessity.
Was medical necessity met in this scenario? Why or why not?
I do
think criteria was met for providing medically necessary services in this scenario
because the appropriate steps were taken to determine that there was an
infection by urine collection that tested positive for white blood cells and further
tests ordered can be used to determine the type of bacteria that existed by
performing a culture of the urine and letting the bacteria form for
identification of bacteria type to guide how to best treat the infection. “A
bacterial urine culture is a laboratory procedure performed on a urine specimen
to establish the probable etiology of a presumed urinary tract infection. It is
common practice to do a urinalysis prior to a urine culture.” (CMS.gov,
Urine Culture, Bacterial, para. 1.
References
Documentation,
Coding, Billing, and Compliance, para. 8. https://radiologykey.com/documentation-coding-billing-and-compliance/
CMS.gov,
Urine Culture, Bacterial, para. 1., https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=25&ncdver=1
Comstock,
J., CPC, Two Medicare cases illustrate the importance of NCDs and LCDs, para1.,
https://www.aapc.com/blog/36245-the-secret-to-proving-medical-necessity/
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