General Surgery Coding Alert
Dispelling the Myth of V Codes and Primary Diagnoses
Although it is inappropriate to use many of the V codes to report primary diagnoses, some V codes are the only choice for providing medical necessity for a procedure.
The introduction to the V Codes section of the ICD-9 manual states that they are used when:
1. A person who is not currently sick encounters the health services for some specific purpose, such as to act as a donor of an organ or tissue, to receive prophylactic vaccination, or to discuss a problem which is in itself not a disease or injury.
2. A person with a known disease or injury, whether it is current or resolving, encounters the health care system for a specific treatment of that disease or injury (e.g., dialysis for renal disease, chemotherapy for malignancy, cast change).
3. Some circumstance or problem is present which influences the persons health status but is not in itself a current illness or injury.
Referring to the third set of circumstances for using V codes, the introduction states: In the latter circumstances the V code should be used only as a supplementary code and should not be the one selected for use in primary, single cause tabulations. Examples of these circumstances are a personal history of certain diseases, or a person with an artificial heart valve in situ. The wording of this passage may have helped perpetuate the myth that V codes should not be used to report primary diagnoses.
Note: In fact, personal history codes are among the V codes most frequently used appropriately as primary diagnoses, along with codes for artificial openings and prophylactic organ removal.
Personal History
Personal history (and some family history) V codes are frequently required as primary diagnoses for high-risk screening colonoscopies, mammography, follow-up visits for cancer, and other services.
Medicare covers one screening colonoscopy every two years for beneficiaries at high risk for colorectal cancer. To qualify for these screenings, which are coded G0105 (Colorectal cancer screening; colonoscopy on individual at high risk), the patient must have at least one of three conditions: (a) family history of colorectal cancer or adenomatous polyposis; (b) personal history of adenomatous polyps or colorectal cancer; or (c) inflammatory bowel disease (for example, Crohns disease or ulcerative colitis).
Personal and family history are indicated with one or more of the following V codes, reported as the primary diagnosis for the high-risk screening colonoscopy:
V10.05 Personal history of malignant neoplasm; large intestine
V12.72 Personal history of colonic polyps
V16.0 Family history of malignant neoplasm; gastrointestinal tract
V18.5 Family history of digestive disorders.
As of July 2001, Medicare also pays for a low-risk screening colonoscopy once every 10 years. This service, which is coded G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk), must be associated with ICD-9 code V76.51 (Special screening for malignant neoplasms; colon), says Elaine Elliott, CPC, a general surgery coding and reimbursement specialist in Jensen Beach, Fla. If another diagnosis such as abdominal pain is used, it is likely this screening colonoscopy will be denied.
When a patient who has been treated for cancer sees the surgeon for an annual checkup, the appropriate personal-history-of-cancer code should be associated with the E/M code that is reported. It is incorrect to use a cancer diagnosis as a strategy for payment if the patient is free of cancer (i.e., the neoplasm has been removed and the patient is no longer receiving oral medication or chemotherapy) even when the carrier does not pay for any other diagnosis, including the appropriate V code. Most carriers, however, will pay for follow-up E/M when the V code is used.
Artificial Openings
A code from the V44.x (Artificial opening status) series is used when the surgeon examines an artificial opening on a patient, such as a gastrostomy tube or colostomy. These openings require periodic checking, which is the primary reason for the examination. For example, if the surgeon examines the condition of a patients gastrostomy tube, the appropriate E/M code may be reported with a diagnosis code of V44.1. At other times, the surgeon may be required to change a gastrostomy tube or repair a colostomy. In such cases, another V code from the V55.x (Attention to artificial openings) series is reported as the primary diagnosis, linked to the appropriate CPT code.
For example, a surgeon may decide that a gastrostomy tube needs to be replaced even though there is no mechanical problem or complication. Sometimes, these devices just need to be changed. They can become chronically partially obstructed, aneurysmal or simply just skanky, says M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C. In either case, other ICD-9 codes are inappropriate, and V55.1 should be reported along with the gastrostomy tube change.
Prophylactic and Other Procedures
Organs may be removed prophylactically: The ICD-9 manual includes the V50.4x (Prophylactic organ removal) series for these procedures. For example, a patient with a personal and strong family history of breast cancer may decide to have the remaining breast removed prophylactically for the very real fear of a future breast cancer, Dunaway says. Once removed, the breast is sent to pathology. If the pathology report returns positive, the appropriate breast cancer diagnosis should be used. But if the report is negative, code V50.41 should be reported.
Another V code that may be used to report a primary diagnosis is V58.81 (Fitting and adjustment of vascular catheter). When a vascular catheter requires removal or replacement, there often is not an accompanying disease or sign or symptom. Therefore, V58.81 should be associated with the appropriate catheter removal or replacement code.
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