Primary Care Coding Alert

Our guidelines spell out the requirements for aftercare, V codes

What should you do when you see a V code listed first on your family physician's claims? This is just one of the coding questions that you may encounter when dealing with ICD-9 coding.

We-ve compiled three coding scenarios and the corresponding solutions to help you overcome these common diagnosis coding challenges. Report All Documented Diagnoses Snag 1: A physician dictates -Primary Diagnosis: Sprained Rotator Cuff (840.4)- in his documentation for a shoulder injection (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]), but later in the body of the documentation, the FP also notes that the patient has adhesive capsulitis of the shoulder (726.0).

The coder researches the payer's policy on 20610 and finds that 840.4 (Sprains and strains of shoulder and upper arm; rotator cuff [capsule]) is not a covered diagnosis for 20610, but 726.0 (Adhesive capsulitis of shoulder) is payable.

Coders are routinely taught to list the physician's primary diagnosis as the ICD-9 code on the claim form. Can this coder use adhesive capsulitis as the diagnosis on the physician's claim, or must she stick with the rotator cuff sprain?

Solution: -As long as it is documented, you are permitted to choose whichever diagnosis supports the procedure,- says Susan Vogelberger, CPC, CPC-H, CMBS, owner and president of Healthcare Consulting & Coding Education LLC in Boardman, Ohio.

-You can even choose the diagnosis from the body of the documentation if what's listed at the top is a non-allowed diagnosis,- she says. But it would be incorrect to use a diagnosis code that the physician did not document but gets the claim paid, she says.

Why would the physician list the primary diagnosis as a rotator cuff sprain, even if he performed the injection for the adhesive capsulitis?

-Often the doctors are not aware of the local coverage decisions, etc., so they just list the diagnoses in whatever order comes to mind,- Vogelberger says. -It's the coder's job to find the correct diagnosis to support a claim based on the medical necessity.-

Bottom line: The physician may list the primary diagnosis using any of the patient's conditions, but that doesn't mean you have to list that ICD-9 code on your claim. If he dictates another, payable diagnosis, you should list that instead.

In our example above, the coder should report 726.0 followed by 840.4 as her diagnoses. Go Ahead: List V Codes as Primary Diagnoses Snag 2: A patient has a 2.0-cm laceration on her hand, which an emergency department physician repaired in the ED. The emergency physician billed for the surgical repair with 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including [...]