# Clinical Policies...Ok in an audit???



## AmandaW (Nov 30, 2010)

Is it ok to have a 'Clinical Policy'?  For instance, at my clinic, the doctors want to do the cancer diagnosis 5 years out of treatment. I believe in the Medicare guidelines or it might just be in the ICD-9 guidelines, your supposed to code history of neoplasm when they are off treatment. Would we be ok in an audit???


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## btadlock1 (Dec 4, 2010)

I think these ICD-9 guidelines may be relevant here:
*When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. *Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code.

Personal history codes may be used in conjunction with follow-up codes and family history codes may be use in conjunction with screening codes to explain the need for a test or procedure. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.
The history V code categories are:
V10 Personal history of malignant neoplasm


For accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses *as well as symptoms, problems, or reasons for the encounter*. There are ICD-9-CM codes to describe all of these.

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. *Do not code conditions that were previously treated and no longer exist.* However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (*Outpatient*, if visit is unrelated to follow-up of resolved condition)

Previous conditions
If the physician has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some physicians include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that *have no bearing on the current stay*. Such conditions are not to be reported and are coded only if required by hospital policy.
However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. *(Inpatient only)*

Aftercare visit codes cover situations _when the initial treatment of a disease or injury has been performed and the patient requires continued care *during the healing or recovery phase, or for the long-term consequences of the disease. *_*The aftercare V code should not be used if treatment is directed at a current, acute disease or injury, the diagnosis code is to be used in these cases.* Exceptions to this rule are codes V58.0, Radiotherapy, and V58.1, Chemotherapy. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy or chemotherapy for the treatment of a neoplasm. Should a patient receive both chemotherapy and radiation therapy during the same encounter code V58.0 and V58.1 may be used together on a record with either one being sequenced first.
Certain aftercare V code categories need a secondary diagnosis code to describe the *resolving condition *or sequelae, for others, the condition is inherent in the code title.

*The follow-up codes are for use to explain continuing
surveillance following completed treatment of a disease,
condition, or injury. They infer that the condition has been
fully treated and no longer exists.* They should not be
confused with aftercare codes which explain current
treatment for a healing condition or its sequelae. Follow-up
codes may be used in conjunction with history codes to
provide the full picture of the healed condition and its
treatment. The follow-up code is sequenced first, followed
by the history code.
A follow-up code may be used to explain repeated visits.
*Should a condition be found to have recurred on the follow-
up visit, then the diagnosis code should be used in place of
the follow-up code.*The follow-up V code categories:
V24 Postpartum care and evaluation
V67 Follow-up examination

Brandi Tadlock, CPC, CPMA


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## AmandaW (Dec 6, 2010)

Thank you very much Brandi...lots of valuable info.  More so though, I was wondering if we would be ok in an audit with this whole 5 years out from treatment thing.  The absolute right thing to do would be code history as soon as they are off treatment, but the docs don't want to code history until 5 years out from treatment.  To be honest, I'm sure it's b/c of a getting paid issue.  Our doctors of course want to keep up on scans, and keep doing survelience CT's, etc. but a lot of history of cancer codes don't pay for those kinds of things. I just hope that we would be ok in an audit.


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## btadlock1 (Dec 7, 2010)

If the patient's not in treatment, then they should not code a diagnosis that indicates a current problem. I'd advise to stick with the aftercare codes, since they allow for close monitoring to continue. I interpret it as:

A diagnosis from the numerical codes = currently treating an active problem
Aftercare codes = Not currently treating the problem, but we're watching it closely to make sure it continues to improve and doesn't relapse
Follow-up codes = it appears as though the problem no longer exists, but we're checking to make sure that it's gone.

Carefully read all of the guidelines that pertain to neoplasms, and V-codes, as well as selecting principal and additional diagnoses. If they're not being followed, corrective action should be taken immediately. If they are *intentionally* billing the wrong code for the patient's status to get paid more, they are most definitely breaking the law. Remind them that the OIG assesses fines of up to $10,000 + 3 times the amount paid on the fraudulent claim, and that is *per claim*. They don't just audit 1, either.


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## AmandaW (Dec 7, 2010)

SO...if they are just SO adiment about doing it THEIR way (and I really need my job like everyone else!) I wonder if I would get in trouble as the CPC with the auditor, or fined some how or would it all be on the docs?  I'm guessing it just all depends on the auditor and all.  I also work with 3 other CPC's that have to be on the same page as me and that's not always easy, ya know?!


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## btadlock1 (Dec 7, 2010)

Legally, it falls on the doctor. They are ultimately responsible for their documentation and the contents of their claims. You might have some liability if it can be proven that you knew about the fraud and didn't speak up, or even actively participated. If you really have doubts, you should first talk with the doctor about your concerns, but if they refuse to listen, don't go down with the ship. I'd start looking for somewhere else to work, and notify someone of the problem. Tread lightly, though. You don't want to jeopardize your career or someone else's by jumping to conclusions too early. Things aren't always as they seem.


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