Pathology/Lab Coding Alert

Question: When physicians order labs before a procedure, they often identify the reason for the test using a code such as V72.69 and we (the lab) have problems getting paid. What’s the problem, and what can we do to get paid?

Texas Subscriber

Answer: You should get your physician clients to order the pre-procedure lab test(s) based on the diagnosis that is the reason for their procedure. They can assign the appropriate “V” code in addition to the signs, symptoms, or condition that is the reason for the encounter.

CPT^® provides five V codes for lab encounters:

• V72.60 — Laboratory examination, unspecified
• V72.61 — Antibody response examination
• V72.62 — Laboratory examination ordered as part of a routine general medical examination
• V72.63 — Pre-procedural laboratory examination
• V72.69 — Other laboratory examination.

Although V72.60-V72.69 add specificity to reporting encounters for lab tests, you shouldn’t routinely use one of them as the only code for a lab exam. Note that ICD-9’s “Official Guidelines for Coding and Reporting” state you shouldn’t use V72.6x as the primary diagnosis if you have documentation of “a sign or symptoms, or reason for a test.”

This guidance clarifies that you shouldn’t start billing all pre-op or routine-physical lab tests with V72.6x. Because the ordering physician, not the laboratory, assigns the ICD-9 code, you’ll need to help your physician clients understand how they should and shouldn’t use the codes. V codes describe the reason for the encounter, but physicians should still use specific condition codes to describe the signs, symptoms, or disease that show(s) medical necessity for ordered tests.

You can use physician education opportunities and requisition-form design to encourage proper ICD-9 use. Informing physicians that they need to continue ordering lab tests with condition codes will help your lab show medical necessity and get paid for ordered tests.

Does that mean you can’t use V72.6x as a primary diagnosis? No. ICD-9 indicates that you can use the code as a first-listed or additional diagnosis. You should only list V72.6x as the primary diagnosis “in the absence of any signs, symptoms, or associated diagnosis,” according to ICD-9 official guidelines.

Bottom line: If you perform diagnostic lab tests based solely on one of the lab exam V codes, Medicare and other payers will likely determine that you haven’t demonstrated medical necessity and decline to pay.