Primary Care Coding Alert

Surprise: You'll find the V71 series useful for suspected non-ill cases

If you automatically assign V65.5 whenever your family physician doesn't have a clear diagnosis for a pediatric visit, you could be overlooking two more appropriate V code series: V67 and V71.
 
For an encounter in which a child who has a history of otitis media (OM) is not now ill, coders recommend reporting V65.5 (Person with feared complaint in whom no diagnosis was made) in the secondary position, writes Carol Miller, CPC, coder in the charge entry department of the Family Health Center in Orlando, Fla. "What diagnosis should you use in the first position?"
 
Find out how ICD-9 experts recommend coding three "well check" scenarios.

1. Use V71 Series for Nonsymptomatic Rule Out

Because ICD-9 disallows rule outs or suspected conditions, coding an unfound injury proves problematic. But you can code these encounters as examinations for unfounded suspected conditions (V71.x, Observation and evaluation for suspected conditions not found).
 
You should use this category "when persons without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is found not to exist," state ICD-9's instructions following V71.
 
Scenario: A family physician sees a child for a suspected "broken [fore]arm." There is no sign or symptom of a break, and the FP rules out the condition.
 
Solution: You should report the E/M services (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) with V71.89 (Observation and evaluation for other specified suspected conditions).
 
When a physician rules out a suspected condition, you should use the V71 series, says Jeffrey Linzer Sr., MD, MICP, FAAP, representative to the ICD-9-CM editorial advisory board.

2. Let Symptom Override V Code

If the FP makes a diagnosis or documents a sign or symptom, you should instead report the problem with the appropriate ICD-9 code.
 
For instance, in the suspected broken forearm scenario, "if the child had just hurt his arm and there was no fracture, you would use the code for '[fore]arm injury' (959.3, Injury, other and unspecified; elbow, forearm and wrist)," Linzer says. Because the physician was able to diagnose an injury - albeit not a break - to the arm, the use of 959.3 rather than V71.x is appropriate
 
Anther example: After her 6-month-old baby rolls off the bed, a mother brings the infant to the FP to make sure he's OK. The physician examines the baby and finds no bruising, swelling, head injury or tenderness.
  
To report the accident with no found injuries and no signs or symptoms of such, you would report V71.4 (Observation [exam] following other accident). "If, however, there was a contusion or some physical evidence of the fall, you would document that condition as the primary diagnosis," says Jean S. Oglevee, CPC, coding specialist at Family Medicine Centreville in Centreville, Va. To show the fall was from a bed, you would assign E884.4 in the second position.

3. Describe Resolved Condition With V67.x

Before you use V71.89, check that the patient didn't previously have the condition. If an FP examines a child for a previous problem that the physician no longer finds, you should assign a code from the V67 series.
 
Example: Prior to flying to grandma's house for Memorial Day weekend, a parent presents with her child who recently recovered from an ear infection or OM. "I just want to make sure everything is OK," the mother tells the FP.
 
Answer: In this scenario, you would report the E/M service linked to V67.9 (Unspecified follow-up examination). This ICD-9 code assumes the child did not receive any treatment and the condition (OM) is resolved, Linzer says.
 
Tip: If the FP had previously treated the condition, you would instead use V67.59 (Follow-up exam following other treatment; other). You would count prior OM antibiotic treatment as "other" in ICD-9's V67.59 descriptor. 
 
Added case: A father presents with his 1-year-old son, who has a history of tubes placement, to make sure the tubes are still present prior to flying. As long as the condition is no longer present, you would report V67.59.

4. Reserve V65.5 for Normal Problem

Despite frequent advice on reporting V65.5, you'll rarely have a valid reason to use this code. "It's a good code for a hypochondriac," Linzer quips. You would assign V65.5 "when a person comes in with a complaint that is actually a normal finding."
 
Encounter: A person presents for an office visit stating, "I sneeze when I'm around pepper. Does that mean I'm allergic?"
 
You code: Because the patient's problem is normal, you would code V65.5 with 99201-99215. The diagnosis literally represents a person "in whom no diagnosis was made." In contrast, the resolved OM child had a previous condition, and the forearm injury patient had a suspected condition.
 
Lesson learned: The V71 codes are more useful than V65.5 for instances in which a person presents with a complaint and the FP finds no significant condition.