Orthopedic Coding Alert

On June 20, CMS announced the ICD-9 code changes for 2003. The revisions most relevant to orthopedists are listed on page 70, with the new aftercare codes, V54.10-V54.89, V58.42 and V58.43, leading the group as the most significant for day-to-day orthopedic coding operations. V codes (unlike E codes) can be used as primary diagnoses and, therefore, often make or break carriers' reimbursement decisions.

"It is a common misconception that V codes cannot be listed as primary diagnoses," says Laureen Jandroep, OTR, CPC, CCS-P CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J. "Sometimes the V code is the most accurate choice and should be placed first on the claim."

Problem-Oriented V Codes

ICD-9 recognizes three types of V codes: problem-oriented, fact-oriented and service-oriented. "The problem-oriented codes are those most likely to be used as primary diagnoses," Jandroep says.

For instance, says Tom DeWitt, office manager at Fairfield Orthopedic Associates in Connecticut, "We once had a patient who was bitten by a stray dog, and she thought she might have a broken arm. It turned out she was actually fine, but the orthopedist decided to send her for rabies tests. We coded the examination using the V code for exposure to rabies (V01.5), then we added E906.0 to show that she had been bitten by a dog."

Fact-Oriented V Codes

"The fact-oriented V codes are most often listed as secondary codes," Jandroep says. "They help round out the story but don't describe the reason the patient is there."

For instance, a 9-year-old patient presents to your orthopedic practice complaining of stiff joints. Her mother explains that several family members developed rheumatoid arthritis (714.0-714.33) before age 25. The orthopedist examines the patient and orders an erythrocyte sedimentation rate test (85651-85652) and a rheumatoid factor test (86430-86431).

Some carriers may reject the claim when it's submitted only with the stiff joint diagnosis (719.50-719.59), stating that the tests were unnecessary in such a young patient. However, if in addition to the diagnosis code for joint stiffness you use the "family history of arthritis" code (V17.7), you can explain that the visit is medically necessary due to the child's family history.

Service-Oriented V Codes

Service-oriented V codes include most of the new orthopedic-related additions to ICD-9 this year. For instance, report V54.89 (Other orthopedic aftercare) if the orthopedist removes an external splint or other external fixation or traction device following surgery.

V Codes for Preoperative Clearance

In 2001, CMS instructed all local Medicare carriers to accept V codes to indicate medical necessity for preoperative clearance, but many carriers still deny claims with V72.83 (Other specified preoperative examination) listed as the primary diagnosis. If your carrier routinely denies these claims, you should appeal because many payers have yet to update their systems appropriately.

When using V codes for preoperative clearance, you should also list the appropriate code for the condition(s) that prompted surgery.