ED Coding and Reimbursement Alert

Expect better performing ED claims with this V & E code tune-up.
When it comes to bolstering the medical necessity of your ED claims, V codes and E codes should be an ICD-9 tool that you pull often from your coding toolbox. They can often paint a much clearer picture of that ED patient visit than just the main Tabular List of Diseases.
The ED patient visit picture can often be muddied with non-specific diagnosis coding, making it almost impossible to ascertain just from the ICD-9 codes exactly what brought the patient to the ED for this encounter, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance for Medical Management Professionals in Durham, NC. A clear picture of the encounter must be painted by the diagnostic coding for the payors to agree with the medical necessity of the ED visit and to ultimately pay the claim, she adds.
Take This Quick V Codes Refresher
Essentially, V codes supplement the primary diagnosis but can also describe the primary reason for the visit. A few V-codes facts:
ICD-9 CM manual includes the V code and E code sections as "Supplementary Classifications" to the main Tabular List of Diseases. V codes are defined by ICD-9 as "Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01-V91)".
Some V codes may be used as the principal diagnosis, others may only be used as secondary codes, and some can be used as either, depending on the circumstances.
The rules for sequencing of V codes are different for the outpatient setting than they are for the inpatient setting.
V codes can be particularly relevant in the ED place of service because many ED patients present to the ED without clear disease processes. Many present without any disease process but need various healthcare services, such as to rule-out infectious disease after a possible exposure or for observation after a motor vehicle accident or even for a screening examination prior to admission to another facility, says Norris.
V Codes as Primary? Check With Your Payer
V codes are often the answer in difficult-to-code ED scenarios but the challenge is determining which V Codes they will accept and which they will not. Often payor edits are not published anywhere, and all coders and billers can do is to glean the list of payable and non-payable V codes from their claim experience.
For example: Florida Medicaid considers some "history of" V codes payable, even as a primary diagnosis, and these codes may help to support the medical necessity of the claim. If a patient presents with no symptoms at all and has a history of cardiac disease, and the patient does have some sort of cardiac exam and/or work-up, then the coder can use V12.50, Personal History of Unspecified Circulatory Disease to support the medical necessity of the claim.
In addition, this personal history code could also be used with other diagnosis codes on the claim. However, this same payor will not pay for a claim with many of the follow-up V codes, such as V67.9, (Unspecified follow-up examination).
Drawback: Unfortunately, the screening or follow-up V codes are not payable diagnoses for payors. On the other hand, if the screening or follow-up V code is absolutely the only diagnosis code that can be pulled from the chart documentation, then the coder may have no choice but to submit the V code that will result in a denial and then appeal perhaps with a copy of the medical record.
Get docs on board: Emphasize to ED physician the importance of documenting all presenting complaints and signs and symptoms in the context of avoiding unnecessary denials. Many times, the physician may not be familiar with ICD-9 and what diagnoses are and are not available to coders and how they ultimately impact claim payments, Norris adds.
Look to E Codes Cause of Injury Details
Injuries are one of the top groups of diagnosis for which patients present to the ED. E codes are used to provide additional data and information on injury and poisoning cases. E codes are "Supplementary Classification of External Causes of Injury and Poisoning (E000-E999)". So like V codes, E codes are also considered supplementary codes to the main tabular section in ICD-9.
Unlike V codes: E codes are never to be used as the primary diagnosis. E codes can provide additional information on where the injury happened, how it happened, what the patient was doing when it happened, whether it was accidental, unintentional or intentional and the place that it occurred. With all that added detail, it is easy to see how E codes can help to more fully describe the circumstances of the ED visit and to further support the medical necessity of the claim, say Norris.
Be Guided By This E Code Example
For example, offers Norris, if a child has a final diagnosis of a fairly simple injury, such as ICD-9 code 914.0 (Superficial injury of the hand, abrasion or friction burn without mention of infection), and an ED E/M level 99284 is coded, a payor may question or even deny that claim initially.
However, when E codes are added that further explain the circumstances of the injury, such as E884.0 (Accidental fall from playground equipment), the payor may not deny the E/M code or request that a copy of the medical records be submitted, she adds. The E code describing the detail of the fall allows the payor to better understand the medical necessity of a Level 99284 History, Exam and Medical Decision Making that was necessary to rule-out more severe injuries for the child.
WC angle: Workers Compensation Carriers do usually want or even require E codes on their claims. Conversely, some payors do not want E codes on their claims and may even deny claims when submitted with E codes (most likely because their systems just haven't been updated to accept E codes).
The bottom line: Research must be done on an individual payor basis to determine which payors accept or require E codes and which do not accept them at all, says Norris.