Don’t Fall into the V Code Rut
By Debra Mitchell, MSPH, CPC-H
There is a prevailing notion in the health care industry that V codes cannot or should not be cited as a first-listed diagnosis. This is incorrect for several reasons:
- Health Insurance Portability and Accountability Act (HIPAA) establishes ICD-9-CM (Vols. 1 and 2, including the Official
ICD-9-CM Guidelines for Coding and Reporting) as the reporting code set for diseases, injuries, impairments, other health problems, and their manifestations; and causes of injury, disease, impairment, or other health problems. V codes are integral to ICD-9-CM and neither payers nor providers may deem them as unacceptable.
- The Official ICD-9-CM Guidelines for Coding and Reporting identifies specifically those V codes that may be used in the first-listed position (including some that should be used only in the first-listed position), as well, and those V codes which may never be first listed. This information can be found in the V code table, page 80 of the October 2008 version of the coding and reporting guidelines: www.cdc.gov/nchs/datawh/ftpserv/ftpICD9/icdguide08.pdf.
- The diagnosis belongs to the patient, and should not be altered to meet the needs of the provider or payer. If a V code best explains the reason for the patient encounter, medical and coding accuracy require you to assign that code.
To determine if a V code appropriately describes a patient encounter, ask yourself, “What is wrong with the patient?” If no acute medical problem or issue is documented, then you are likely to need a V code as the first-listed diagnosis.
Aftercare vs. Follow-up
The difference between aftercare and follow-up is the type of care the physician renders. Aftercare implies the physician is providing related treatment for the patient after a surgery or procedure. Follow-up, on the other hand, is surveillance of the patient to make sure all is going well.
The coding and reporting guidelines specify that after the problem has been treated and has healed, you should not report the surgical aftercare using a code for the problem existing prior to the surgery. Acute injuries are treated the same way; after initial injury and treatment, the acute injury no longer exists and the visit is coded using aftercare or follow-up codes.
Code V58.4x Other aftercare following surgery should be reported with the V code that indicates the type of aftercare delivered. For suture removal following a laceration repair, for example, use the aftercare code V58.43 Aftercare following surgery for injury and trauma along with V58.32 Encounter for removal of sutures. These two codes alone complete the claim and tell the entire reason for the encounter.
Fracture aftercare is often coded incorrectly, as well. The codes for the acute fracture (800-829) may be used while the fracture is acute and prior to treatment. After fracture treatment is rendered, do not code the fracture as acute. Instead, a code from category V54.1x Aftercare for healing traumatic fracture will describe any encounter or service as healing traumatic fracture aftercare.
Neoplasm surgery aftercare is an exception to the use of acute codes for aftercare. If the visit is for chemotherapy or immunotherapy administration, V58.1x Encounter for antineoplastic chemotherapy and immunotherapy is used as a first-listed code, with a code for the neoplasm as secondary. When all treatment for the neoplasm has ceased and the physician documents no evidence of disease, V10.x Personal history of malignant neoplasm is appropriate.
All follow-up (not aftercare) visits are reported using codes from the V67 Follow-up examination category. Follow-up codes may be used following surgery or other procedures, including chemotherapy, radiation therapy, high-risk medications, and healed fractures.
Observation for Conditions Not Found
If a skin lesion has been removed with a full thickness excision, the visit and procedure may not be coded until the pathology is returned. Neoplasm of uncertain behavior (235-238) should not be reported unless that diagnosis is rendered by the pathologist.
After the excision is performed, the claim must be held until the pathology report is received. If pathology returns a benign diagnosis—or any diagnosis other than malignant—the visit is best coded with V71.1 Observation and evaluation for a suspected malignant neoplasm not found first-listed, followed by the benign condition code. This combination communicates the encounter’s exact nature, as well as the true patient diagnosis as documented by the physician. The documentation should support the physician performing the excision due to a suspicion for a malignancy.
If the excision is not performed at this encounter, the office visit is coded as a skin abnormality with 709.8 Other specified disorders of skin because you should not report suspected, probable, or possible conditions.
Pregnancy Diagnosis Determines V Code Selection
Almost every coder will agree that a pregnancy supervision visit is coded using a first-listed diagnosis of V22.1 Supervision of other normal pregnancy or V22.0 Supervision of normal first pregnancy. The major problem is the overuse of V22.2 Pregnant state incidental, which should be listed as a secondary code only. This code requires specific physician documentation that the treated condition is not complicating the pregnancy management. Because this documentation rarely is obtained, V22.2 is not to be used. To illustrate correct (or, more precisely, incorrect) code usage, consider the following two scenarios.
Scenario 1: A patient is seen for asthma and is also pregnant. The physician will need to document that the asthma is a condition not affecting the patient’s pregnancy management to report V22.2 secondary to the appropriate asthma code. Without this documentation, the correct first-listed code will be 648.93 Other current condition in mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium; other current conditions classifiable elsewhere; antepartum condition or complication. The secondary code is for the asthma, as documented.
Scenario 2: The patient presents to the physician office for examination because she has a suspicion she might be pregnant. Some coders will report this as 626.0 Absence of menstruation. If the physician has not documented the condition, this diagnosis is incorrect. Code 626.0 is in the chapter for genitourinary system diseases, but it shouldn’t be reported for a patient of child-bearing age who thinks she is pregnant. The definition for 626.0 is “the absence of menstruation prior to the age of 16 or for a period of 6 months or greater.” This patient has no acute illness and presents completely normal so a V code is needed for this encounter. Code V72.4x Examination or test for pregnancy is a code sub-category created for exactly this type of encounter.
Don’t Jump to Conclusions
Be careful when selecting the patient’s diagnosis codes, and code only from what the physician documents.
If a payer does not pay the claim, it is not necessarily due to the presence of a V code. It could be a coverage issue; many payers do not pay for routine preventive encounters and screening. Certain encounters and procedures are considered to be the patient’s responsibility and, as such, are statutorily not covered by the patient’s plan. If this is the case, the payment for the visit becomes the patient’s responsibility.
For instance, a patient is scheduled for her yearly preventive examination. There is no problem with this patient at this encounter, and V70.0 Routine general medical examination at a health care facility is the appropriate, first-listed code choice.
Even if the patient has a chronic condition(s), you should report V70.0 as the first-listed code for an otherwise asymptomatic patient. Chronic conditions may be listed as secondary, contributory diagnoses, but the mere existence of a chronic condition does not change a wellness exam into a problem-focused E/M visit. To list a chronic condition as the primary diagnosis for a preventive service to receive payment from the insurer is inaccurate and fraudulent coding.
If the visit or procedure is a screening, the coding and reporting guidelines state that the V code for the screening is the first-listed code regardless of any findings or subsequent procedure performed at that setting. For example, if the patient presents for a screen colonoscopy, the first-listed code for the procedure will be V76.51 Special screening for malignant neoplasms of the colon. If a polyp is discovered and removed, the V76.51 will remain first-listed with the polyp as an incidental finding secondary.
Debra Mitchell, MSPH, CPC-H, is a consultant and auditor for coding and compliance with mare than 30 years of experience. She is a professional instructor in coding, billing, and medical terminology at the college level. She teaches a two-day coding workshop and is a consultant for orthopedic and cardiology billing companies. She was recently named to the Biltmore’s Who’s Who in America’s Professional Women.