Neurology & Pain Management Coding Alert

The Centers for Medicare and Medicaid (CMS, formerly HCFA) has instructed all local Medicare carriers to accept V codes for preoperative clearance. Until now, many carriers have routinely denied reimbursement for preoperative consults by neurologists and other specialists. The announcement singles out four preoperative clearance ICD-9 codes. These are:
 
V72.81 (preoperative cardiovascular examination);
V72.82 (preoperative respiratory examination);
V72.83 (other specified preoperative examination);   
V72.84 (preoperative examination, unspecified)  
The clarification, which revises section 15047 of the Medicare Carriers Manual (MCM), states that V72.81-V72.84 should be used to indicate medical necessity for preoperative clearance evaluations.
 
Medicare transmittal R1707-B3, issued May 31, 2001, instructs carriers to "delete any processing edits that deny claims or identify for manual review V72.81-V72.84." However, "claims containing these codes are subject to medical necessity determinations as described in MCM section 15047H."
 
According to the new language in section 15047C, Medicare will pay for all medically necessary preoperative clearances, such as those that involve "evaluating a patient's risk of perioperative complications and to optimize perioperative care." Local Medicare carriers retain the discretion to determine the medical necessity, CMS says.
 
"Medicare probably issued this to set the carriers straight," says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "Many carriers routinely denied these services on first submission when the V codes were correctly used as a primary diagnosis."
 
After the denial was appealed and the claim was reviewed manually, it usually was paid, Callaway says. But, she notes, not all denials are appealed. The new revision should result in far fewer denials when neurologists use a V code as the primary diagnosis.
 
According to the revised language in section 15047G, "all claims for preoperative medical examination and preoperative diagnostic tests (i.e., medical evaluations) must be accompanied by the appropriate code for preoperative examination (e.g., V72.81- V72.84)."  
 
Additionally, the appropriate code for the condition(s) that prompted surgery must also be documented. Other diagnoses and conditions affecting the patient (presumably, the condition that concerned the surgeon enough to send the patient to the neurologist for a preoperative clearance) should also be documented, if appropriate.
 
In other words, when a patient is sent to a neurologist for preoperative clearance, the appropriate V code, rather than the condition that prompted the concern or the condition that warrants surgery, should be listed first to justify the examination. In fact, the transmittal specifies, "The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81-V72.84)."
Payment for Preoperative Consults 
 
The clarification also means that neurology coders can use the appropriate ICD-9 code to get paid for preoperative consults, Callaway says, noting that in states where local Medicare carriers routinely deny consult claims [...]