Internal Medicine Coding Alert

Many coders avoid the V codes because they have a bad reputation as a series that doesn't bring reimbursement. But V codes are often the right and ethical diagnosis choice and many payers do reimburse for procedures and services linked to V codes.

"We tell our clients not to be afraid of the V codes," says Judy Richardson, RN, MSA, CCS-P, a senior consultant at Hill and Associates, a coding and compliance consulting firm in Wilmington, N.C. "Know that you can and should use them when they are the appropriate diagnosis code."

The ICD-9 manual instructs you to use V codes in three main circumstances:

1.when a healthy person without signs or symptoms comes to the office for a specific purpose, such as an annual exam
2.when a person with a known disease or injury comes for specific treatment of that disease or injury, such as dialysis for renal disease
3.when a patient comes in whose health status is influenced by something other than a known disease or injury, such as a personal or family history of cancer.

Sometimes coders will shy away from the V codes and search for an active disease code to use, thinking that the patient's insurance will not pay for a visit when they use a V code as the primary diagnosis, Richardson says. Medicare and private payers, however, accept more V codes than most coders realize, Richardson says.

Whether the patient's insurance accepts the code should not be the deciding factor that coders consider in selecting a diagnosis code, says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.

"What they really want to do is carefully ascertain the reason for the visit," Rappoport says.

Choose V for Well Visits

When a patient comes in for a well woman check or physical and has no signs or symptoms of disease, you should choose a V code as the primary diagnosis, Richardson says.

"If the patient has come in for an annual exam, V70.0 (Routine general medical examination at a health care facility) is the appropriate code," Richardson says.

Medicare will not pay for annual well exams, but increasingly, private payers pay for these checkups, Richardson notes. If your patient has a policy that covers well checkups, you should get paid using V70.0 as the primary diagnosis code, she says. If the patient's policy does not cover annual checkups, the carrier will not pay for an office visit with this diagnosis, Richardson says. If the patient has no signs or symptoms of disease, however, it is unethical to code the visit with an active disease code, she adds.

If patients have insurance that doesn't cover well visits, they will often ask the office to change the diagnosis for the office visit from V70.0 to a covered one such as upper respiratory infection or sinusitis, Richardson says. Resist this pressure, she advises.

"You are being asked to commit fraud," Richardson says.

Using incorrect diagnosis codes can also skew national disease statistics because the government uses many of the Vcodes for demographic studies, Rappoport says.

Explain Tests for Long-Term Drug Use

You should also choose a V code when a patient who is on a high-risk drug for an extended period comes in for a regular test to assess the drug's effectiveness and toxicity. For example, code a visit to monitor medication levels in a patient receiving Coumadin with V58.61 (Long-term [current] use of anticoagulants).

"This can be your primary diagnosis code," Richardson says. "It is the flag that tells the payer why you did the prothrombin time (PT) test."

Medicare will usually pay for this code for monitoring patients receiving drugs such as Coumadin, tamoxiphen, digoxin or heparin on a long-term basis, Richardson says. Because Medicare doesn't cover well checks and therefore doesn't recognize V codes for well exams, many coders incorrectly assume that all V codes are forbidden with Medicare, Richardson says.

"Medicare is more comfortable with V codes than the commercial field is," Richardson explains.

Use V Codes As a Secondary Code

You will use other V codes most often as secondary codes after active disease codes.

"Some V codes are really not meant to be primary codes," Richardson says. "Use a V code to give extra information and provide supportive evidence for what you are doing."

For example, 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, Richardson says.

"The V code validates that there's something that justifies all we plan to do," Richardson notes.

The V code also further explains an accident, disease or injury and the treatment you are providing. For example, a patient comes to the office after stepping on a rusty nail. The primary diagnosis would be the injury code, but you would 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.

Distinguish between Active and Inactive Disease

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 coders 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, he says. Generally, you should use an active disease code instead of the V10 series when the patient has completed chemotherapy recently and the outcome is not known, he explains. Use the V10 series as a diagnosis when appropriate after the patient's cancer is inactive and no longer under treatment. For example, a patient moves to a new city and establishes with a new internist and mentions a history of prostate cancer 10 years ago. You would use V10.46 (Personal history of malignant neoplasm; prostate) as a secondary diagnosis code at this initial visit.

Some physicians and coders suggest using the V10 series when the active period of treatment has ended and the cancer has not recurred. "If it has been one to two years since the patient was treated for active cancer, then you would go to 'personal history of,'" Richardson says.

Others disagree, she notes. "Some physicians say they never change to 'personal history of,'" Richardson says.

Active Code Can Cause Insurance Issues

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 writing "breast cancer" in the patient's record. This may lead the coder to choose an active breast cancer code in the 174 or 175 series, when the physician intended to note that the patient has a personal history of breast cancer (V10.3) or a family history of breast cancer (V16 series), Rappoport says.

Coders should encourage physicians to be very specific in the diagnoses they record and should check the documentation themselves if they have questions about whether the doctor intended to code an active disease, Rappoport advises.

"To label a patient as having breast cancer or ovarian cancer or prostate cancer when it is no longer active is a very, very wrong thing to do," Richardson says.

When a patient is tagged with cancer rather than the appropriate V code indicating a personal or family history of that disease, the mistake can be costly for the patient.

"It can have an impact if that person seeks other types of insurance, such as life insurance, or, if she has to change carriers, she may be rated higher and have costs go up," Rappoport says.