MCCG222 – Advanced CPT and HCPCS Level II Coding

Week 4 Medical Necessity Assessment

This Assessment is worth 15% of your overall grade.

Deadline

Due by the end of Week 4 at 11:59 pm, ET.

Completing this Assessment will help you to meet the following:

Course Outcome

• Validate medical necessity for appropriate relationships between diagnosis and coded procedures/services.

Directions

Coders need to ensure medical necessity is met while coding.  Insurance companies will deny payment if the codes do not support medical necessity.  It is also not uncommon for insurance companies to vary in what one plan may cover and deem medically necessary.

For this Assessment, you will review two patient cases and validate that the code assignments made by the encoder meet medical necessity. To begin, log into AHIMA VLab. Then follow the directions for each case below. 

Outpatient Surgery Case – Patient Number 311178

1. Review the Outpatient Surgery Case 311178 in AHIMA VLab, which can be found in Authentic Patient Cases.
2. After reviewing this case, review the code assignments that were made by the encoder in the table below.

	Code Assignment	Code Description
Principal Diagnosis	J353	Hypertrophy of tonsils with hypertrophy of adenoids
Principal Procedure	42820	Tonsillectomy and adenoidectomy;  younger than 12

• After you have reviewed the code assignments, review the Insurance Clinical Indications PDF for the procedures performed, which is provided in Blackboard.
• Now determine whether or not the diagnosis/diagnoses show medical necessity for the procedures performed.  Explain your answer in detail in the box below. (25 points)

Outpatient Clinic Case – Patient Number 410057

1. Review the Outpatient Clinic Case 410057 in AHIMA VLab, which can be found in Authentic Patient Cases.
2. After reviewing this case, review the code assignments that were made by the encoder in the table below.

	Code Assignment	Code Description
Admitting Diagnosis	C50.312	Malignant neoplasm of lower-inner quadrant of left female breast
Secondary Diagnosis or Diagnoses	Z171	Estrogen Receptor negative status
Principal Procedure	19301-RT	Partial Mastectomy
Secondary Procedure	19285-RT	Placement of breast localization device, percutaneous; first lesion, including ultrasound guidance (RT- Right side of the body)
Third Procedure	14301	Adjustment tissue transfer/rearrangement

• Now determine whether or not the diagnosis/diagnoses show medical necessity for the procedures performed.  Explain your answers in detail in the boxes below. (25 points each)