MCCG100 Introduction to Reimbursement and Coding

You are a new coder at Bryant City Hospital.  You have been assigned the three patient records below today to code.  Before you assign the correct codes, you must determine if the procedure performed will meet the medical necessity guidelines required for payment.  Please read each of the scenarios below and determine what the diagnosis (illness or injury) is for the patient and what the appropriate treatment or procedure would be based on that diagnosis.  Each answer should be give in complete sentences an a minimum of 100 words in length.

Read through the example scanario below for guidelines for what each of your answers will look like.

Example Scenario

A patient presents at their physician’s office with a head and chest congestion, sore throat, fever, and body aches.  The patient states that she has suffered from these symptoms for two days.  The doctor performs a rapid influenza swab/test.  The patient tests positive for influenza. 

1. What is the patient’s diagnosis?  The patient has been diagnosed with lab confirmed influenza which would then be coded with an ICD-10-CM code.  

2. Explain what is procedure was performed to prove this diagnosis?  The procedure performed was an examination and evaluation by the physician which would be coded with an Evaluation and Management (CPT) code and a rapid influenza test (CPT code).  

3. Explain the importance of accurately choosing the correct diagnosis and procedure code to achieve medical necessity and justify how it relates to submitting a claim for payment.  This scenario did meet medical necessity.  The procedures performed; the physician exam and the rapid influenza test both were substantiated by the diagnosis of influenza.  The physician used the information gathered during the examination and determined that the patient met the signs and symptoms for influenza and performed the rapid influenza test to confirm that diagnosis.  This diagnosis and procedure do support medical necessity and would be paid on a claim. 

Respond to the questions below in an essay format, double spaced and at least a minimum of 100 words in length.  

1. What is the patients diagnosis?  
2. Explain what procedure is performed to prove this diagnosis? 
3. Explain the importance of accurately choosing the correct diagnosis and procedure code to achieve medical necessity and justify how it relates to submitting a claim for payment.