Primary Care Coding Alert

Question: My supervisor said that when a case involves workers' compensation or a car accident, I should always use V71.3 or V71.4 as the final diagnosis code. But I thought I should reserve these codes for when the family physician finds no injury. Who is correct?

Missouri Subscriber

Answer: You are right that V71.3 (Observation and evaluation for suspected conditions not found; observation following accident at work) and V71.4 (... observation following other accident) apply to encounters during which no signs or symptoms and no definitive diagnosis explain the CPT code.
 
Example: After a patient is involved in a car accident, he presents to the emergency department (ED). On examination, the FP finds a superficial laceration from broken glass.
 
In this case, you should report the laceration with a code from the 910-919 series (Superficial injury). To identify that a motor vehicle accident caused the injury, you should also assign an E code from section E810-E819 (Motor vehicle traffic accidents). Because exam findings exist, code V71.4 is inappropriate.
 
Don't make this mistake: Your supervisor might be misinterpreting V71's last sentence to mean this code always applies to patients admitted to observation. "This category is also for use for administrative and legal observation status," states ICD-9 following V71. That means, when a physician admits a patient to observation status and no other diagnosis applies to the E/M code, you could use V71.x.
 
For instance, after the FP in the above scenario repairs the motor vehicle accident patient's laceration, the physician places the patient under observation care for possible head trauma. The physician wants to keep the patient in observation to see if he develops any central nervous system symptoms.
 
If the patient doesn't develop any problems or exhibit any signs or symptoms of head trauma, you should report the observation care code (such as 99218-99220, Initial observation care, per day, for the evaluation and management of a patient ...) with V71.4. Link the simple repair code (12001-12018, Simple repair of superficial wounds ...) to the laceration diagnosis (910-919).