Home Health ICD-9/ICD-10 Alert

Published on Tue Jan 03, 2006 PDF

RHHI questions medical necessity when V58.69 listed as primary.

If you're still reporting V58.6x (Long-term [current] drug use) as a primary diagnosis, you're coding inaccurately and may be sending up a red flag to your RHHI. As of Dec.1, codes from this series can only be reported as secondary diagnoses, according to the updated ICD-9-CM Official Guidelines for Coding and Reporting.

This code series in particular indicates that the patient is taking a drug, not that the provider is doing anything with the drug, so it is better as a secondary diagnosis, says Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. "These codes have always been considered status codes so this change may not be a surprise to many," she says.

Probes Question Medical Necessity

But according to Cahaba GBA, this change may take some home health agencies by surprise. The RHHI's Sept. 16 announcement that it would conduct a widespread probe into claims reporting V58.69 (Long-term [current] use of other medications) was based on the substantial number of claims with this code listed as primary, a Cahaba spokesperson tells Eli. Claims reviewed during the probe have also seen a substantial denial rate, she says.

The primary diagnosis should be the most intensive, specific reason for skilled services in the home, says the Cahaba source. V58.69 depicts a long-term, chronic condition. Used as a primary diagnosis, this code brings into question the medical necessity of home health services for these patients, which is the reason for the probe the spokesperson says.

Some coders use V58.69 as a primary code to indicate that the agency is providing "medication management," says Selman-Holman. This indicates to an intermediary that the agency is filling medication planners, not providing a skilled service, she says.

V58.6x Lends Support

Use V58.6x codes as a secondary code to identify the type of long-term drug that is involved when your agency is monitoring the therapeutic effect of a drug, says consultant Judy Adams, RN, BSN, HCS-D with Charlotte, NC-based LarsonAllen Health Care Group. Monitoring the therapeutic effect of a drug can be accomplished through lab results or through observing and assessing a patient's signs and symptoms, she says.

Example 1: Your patient is on long-term Dilantin for treatment of seizures. You will be observing the patient for seizure activity and providing teaching related to the seizure disorder, as well as monitoring the therapeutic effectiveness of the Dilantin in controlling seizure activity. For this patient, Adams suggests coding as follows:
 
M0230a: 780.39 (Other convulsions);
M0240b: V58.83 (Encounter for therapeutic drug monitoring); and
M0240c: V58.69 (Long-term [current] use of other medications).

Example 2: You have a patient who has experienced Digoxin toxicity because of an accidental overdose. You will be monitoring the therapeutic effectiveness of Digoxin as the doctor attempts to regulate the dosage for the patient to achieve therapeutic effectiveness without the toxicity. Code for this patient as follows:

M0230a: 972.1 (Poisoning by agents primarily affecting the cardiovascular system, Digoxin);

M0240b: E858.3 (Accidental poisoning by other drugs, agents primarily affecting the cardiovascular system);

M0240c: V58.83 (Encounter for therapeutic drug monitoring); and

M0240d: V58.69 (Long-term [current] use of other medications).
 
Don't overlook: Medical necessity for a V58.6x code should be supported by documentation of the drug-related issue or problem, and when it occurred, within the medical record, says Adams.

Report Prophylactic Use With V58.6x

The updated Official Guidelines include the following additional information about when it is appropriate to use codes from the V58.6x category.

Assign a code from subcategory V58.6x if the patient is receiving a medication for an extended period:

• As a prophylactic measure, such as for the prevention of deep vein thrombosis;
• As treatment for a chronic condition, such as arthritis; or
• As treatment for a disease requiring a lengthy course of treatment (such as cancer).

Don't assign a V58.6x code for medication being administered for a brief period to treat an acute illness or injury, such as a course of antibiotics to treat acute bronchitis.

Note: For the updated ICD-9-CM Official Guidelines for Coding and Reporting, go to www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide05.pdf.