ED Coding and Reimbursement Alert

When ICD-9 2010 takes effect Oct. 1, it will include a beefed-up V code section that can help you prove medical necessity for your provider's ED services. Get to the meat of the changes with this expert advice on the new additions, and some tips on mollifying your claims with V codes new and old.

If you think V codes are just for other healthcare providers, think again -- these codes go a long way toward proving medical necessity for higher-level ED services. "V codes are beneficial when establishing the risk and medical necessity for a patient with an apparent minor compliant," explains Sarah Todt, RN, CPC, CEDC, associate director for QA and compliance at MRSI Inc. in Woburn, Mass.

ICD-9 2010 affords providers more than a dozen new V codes, from V15.52 (History of traumatic brain injury) to V87.46 (Personal history of immunosuppression therapy).

In between, the new ICD-9 lists several ED-relevant V codes, among them:

• V60.89 -- Other specified housing or economic circumstances

• V61.07 -- Family disruption due to death of family member

• V72.63 -- Pre-procedural laboratory examination.

The new V codes will be useful when a patient has a past medical issue that affects present treatment; for example, a patient with a traumatic brain injury, offers Marvel Hammer RN, CPC, CCS-P, ACS-PM, CHCO, with MJH Consulting in Denver. Check out this example of how a V code can change the tenor of a claim, making higher-level ED services more plausible and payable.

Example: A 36-year-old patient who is vomiting and suffering seizures is brought to the ED via ambulance. The ED physician stabilizes the patient, stopping the seizures with several rounds of medications, and orders a CT scan. During the history portion of the E/M, the physician notes that the patient is an amateur boxer who has a history of traumatic brain injury. The physician documents 63 minutes of critical care time, during which time he:

• obtains a history and physical exam

• performs multiple bedside assessments to monitor the anti-seizure medications

• reviews laboratory studies and diagnostic test results

• documents the encounter in the chart.

This is very likely a critical care scenario, if you can prove that all the care the patient received was warranted. On the claim, report the following:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care

• 780.39 (Other convulsions) appended to 99291 to represent the patient's seizures

• 787.03 (Vomiting alone) appended to 99291 to represent the patient's vomiting

• V15.52 appended to 99291 and 76506 to represent the patient's history of brain injury.

Benefit: Including a V code to represent the patient's history of brain injury can only help you collect the $212 that 99291 pays on average (5.88 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666).

(Can't get enough of the new ICD-9 codes? Check 'emall out at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp.)

In the ED setting, V codes are typically not appropriate for the primary diagnosis, though there are exceptions, explains Todt.

Example: A concerned father brings a 5-year-old child to the ED after a moderate-speed motor vehicle accident (MVA). The provider examines the child from head to toe and finds no signs of injury or trauma, though the parents remain very concerned. In this instance, you would report V71.4 (Observation following other accident) as the primary diagnosis.