The V series should be used, but carefully.
Whether the insurer accepts a code shouldn't be the deciding factor in selecting a diagnosis code.
V70.0 is the appropriate code for the patient who comes in for an annual exam.
Use the V10 series after the patient's cancer is inactive and no longer under treatment.
V codes have a bad reputation as a series that doesn't often bring reimbursement. But they're frequently the correct as well as ethical diagnosis choice, and many payers do reimburse for procedures and services linked to them.
The ICD-9-CM manual instructs you to use V codes as the primary diagnosis in two situations:
when an asymptomatic, healthy patient comes in for a specific purpose, such as an annual exam, or
when a patient with a known disease or injury comes for specific treatment of that disease or injury such as dialysis for renal disease.
Doctors who shy away from the codes sometimes search for an active disease code to use, thinking the patient's insurer won't pay if a V code is used as the primary diagnosis, says Judy Richardson, a senior consultant at Hill & Associates in Wilmington, NC. The fact is, Medicare and private payers accept more V codes than you might realize. Medicare is more comfortable with V codes than commercial insurers.
"And anyway, whether your patient's insurer accepts the code shouldn't be the deciding factor in selecting a diagnosis code," says Bruce Rappoport, a physician at RCH Healthcare Advisors in Fort Lauderdale. "Instead, physicians should carefully ascertain the reason for the visit."
For the patient who comes in for an annual exam, V70.0 (routine general medical examination at a health care facility) is the appropriate code, Richardson says. Medicare won't pay for annual well exams, but increasingly, private payers do.
If your patient's policy doesn't cover annual checkups, you may be asked to change the diagnosis for the office visit to a covered one.
"Resist this pressure," Richardson advises. "You're being asked to commit fraud."
Choose a V code also for the regular effectiveness and toxicity tests given to patients who take long-term, high-risk drugs. For example, V58.61 (long-term [current] use of anticoagulants) is the right code for a visit to monitor medication levels in a patient receiving warfarin.
"This is your primary diagnosis code," Richardson says. "It's the flag that tells the payer why you did the prothrombin time, or PT, test." Medicare will usually pay for this code for monitoring patients receiving other drugs too, such as tamoxifen, digoxin, or heparin over extended periods, Richardson says.
Other V codes are used most often as secondary codes after active disease codes.
"Some V codes are not meant to be primary codes," Richardson says. "They're meant to give extra information and provide supportive evidence for the treatment you're providing."
For instance, a patient who had breast cancer 20 years ago comes in with a lump in the breast. The primary code would be 611.72 (lump or mass in breast), but the physician would also use V10.3 (personal history of malignant neoplasm; breast) to back up a decision to send the patient for immediate diagnostic tests.
"The V code validates that there's something that justifies all we plan to do," Richardson notes. It also further explains an accident, disease, or injury and the treatment.
For example, a patient comes to the office after stepping on a rusty nail. The primary diagnosis would be the injury code, but you'd also use V03.7 (need for prophylactic vaccination and inoculation against bacterial diseases; tetanus toxoid alone) to show that you gave the tetanus vaccine as a prophylactic measure, not as a routine booster.
One of the most confusing V code series is V10.x (personal history of malignant neoplasm) because it can be difficult to pinpoint when cancer becomes "personal history."
"Many doctors don't understand when to use the active disease codes and when to use the inactive ones," Rappoport says. "Unfortunately, there are no black-and-white answers." Generally, use an active disease code instead of the V10 series when the patient has completed chemotherapy recently and the outcome is not known. Use the V10 series after the patient's cancer is inactive and no longer under treatment.
For instance, a new patient mentions a history of prostate cancer 10 years ago. You'd use V10.46 (personal history of malignant neoplasm; prostate) as a secondary diagnosis code at the initial visit.
Some coding experts suggest using the V10 series when the active period of treatment has ended and the cancer hasn't recurred.
"If it's been one to two years since the patient was treated for active cancer, then you'd go to 'personal history of,' " Richardson says.
Using an active disease code instead of a V code when a patient is cancer-free can cause major problems for the patient. Sometimes, a physician will inadvertently saddle a patient with a breast cancer diagnosis by choosing an active breast cancer code in the 174 or 175 series when it should have been indicated that the patient has a personal history of breast cancer (V10.3) or a family history of breast cancer (V16 series), Rappoport says.
"To label a patient as having breast, ovarian, or prostate cancer when it's no longer active can have repercussions," Richardson says. The mistake can be costly for the patient.
"It can have an impact if that person goes out to get life insurance, for example. Or if the patient has to change carriers, he or she may be rated higher and have to pay more," Rappoport says.
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Coding Consult: Don't overlook V codes.
Jul. 11, 2003;80:27.