Anesthesia Coding Alert

Question: A patient with a high risk of breast cancer (due to a strong family history of breast cancer) was admitted for reconstructive breast surgery following removal of her breast. How should I code the diagnosis?

Kansas Subscriber

Answer: You have several terms to choose from for diagnosis coding in this case. Step-by-step:

1. Search for the term "Admission" in the ICD-9 index.

2. Beneath the term "Admission," reference the subterm "for."

3. Follow your choices to the subterm "breast."

4. Beneath "breast," look for "reconstruction following mastectomy."

5. The correct code is V51.0.

Once you've arrived that far, look up V51.0 -- which is a new ICD-9 code for 2009 -- in ICD-9's tabular section to check for additional instructions or coding guidelines, such as exclusions.

Note: The surgeon and your anesthesiologist can each submit claims with V51.0 as the primary diagnosis and V16.3 (Family history of malignant neoplasm; breast) as the secondary diagnosis.

These V codes provide additional information and specificity, which helps your coding and helps get your claims paid.

Careful: Carrier guidelines may differ in their use or acceptance of certain V codes, so check their policies before submitting claims.