Radiology Coding Alert

The observation code may bring in over $160, but it isn't always appropriate Although V71.89 appears as a payable diagnosis on scores of local medical review policies, you shouldn't simply list it on every radiology claim that lacks a reimbursable diagnosis.

You should report ICD-9 V71.89 (Observation and evaluation for other specified suspected conditions; other specified suspected conditions) only if the ordering physician requests a screening for a condition that no other ICD-9 Code describes.
  
V71.89 Shouldn't Replace Signs and Symptoms The problem: Many radiology practices have denials similar to the following scenario, which a subscriber submitted to Radiology Coding Alert :

"Our radiology group has faced denials when we perform a radiology procedure that results in negative findings. We submit the claim with the signs and symptoms, but the payers deny the claims. Should we report V71.89 for these claims?"

The reality: "If the radiology practice doesn't have medical necessity using the signs and symptoms, V71.89 probably won't help," says Jeff Fulkerson, BA, CPC, CMC, certified coder for the department of radiology at The Emory Clinic in Atlanta. "The patient must have had medical necessity for the procedure, or the ordering physician wouldn't have ordered the test. If the tests you perform are all negative, you should report the signs and symptoms."

Because the Balanced Budget Act of 1997 requires all referring physicians to supply signs and symptoms that explain why the radiology order is medically necessary, don't accept a physician order that doesn't list signs and symptoms or a definitive diagnosis. Keep Your ABNs at Close Reach But what if the signs and symptoms that the physician documents don't match those listed on the local medical review policy (LMRP) for the procedure? "In this case, when the patient comes in for the service, take her aside and ask her to sign a waiver of liability," (also known as an advance beneficiary notice, or ABN), Fulkerson says. You should also append modifier -GA (Waiver of liability statement on file) to the claim. "This modifier alerts the carrier that we have an ABN on file and have reason to believe that they will deny coverage for the service."

Good idea: "If the study results in a negative finding and the symptoms aren't on the LMRP, the ABN allows us to bill the patient for any balance left after the carrier has processed and denied the claim," Fulkerson says. When in Doubt, Call the Referring Physician If your LMRP doesn't publish a list of payable signs and symptoms, you can use common sense at times because the symptoms that the ordering physician documents may not support medical necessity, says Carrie Caldewey, RCC, CPC, office manager at Redwood Regional Medical Group in Santa Rosa, Calif. "For [...]