OASIS Alert

These 10 tips will help you cut through the coding confusion.

Is V coding just one trick question after another? It probably seems that way to confused clinicians - but you can ace this test by keeping a few tips in mind.

1. Aftercare V codes (V51-58) are for aftercare only. If your orders and assessment include dressing changes for a healing surgical incision, use code V55.3 because, in that aspect of the care, the patient is in recovery from a disease or injury that is no longer present. If the surgical wound is infected, however, then the patient has an ongoing condition that needs treatment, and you would code the wound, says home care coding expert Prinny Rose Abraham, principal with HIQM in Minneapolis.

2. If care is focused on one active medical condition or one aspect of that condition, that active condition is the primary diagnosis. Consider aftercare as a distinct "condition" for a patient after the treatment for the acute disease is over. Aftercare V codes are primary when the main purpose of the home care is to provide "continued care during the healing or recovery phase" of a formerly acute disease, "or for long-term consequences of the disease," according to the official ICD-9 coding guidelines. The actual disease requiring the aftercare then becomes a secondary diagnosis explaining the need for the V code (see chart  this issue for V codes most often used in home care).

3. Look to your coding manual. V codes have conventions - found in the front of the coding manual - that tell you if they can be used as primary or as secondary only. If the manual doesn't specify one or the other, then the position depends on the reason for the encounter.

4. The "use additional code" note doesn't mean the additional code must follow right after the initial one. The note "use additional code" in the tabular list indicates that the additional code should be used if information is available to elaborate on your selected diagnosis, but it doesn't dictate successive sequencing, advises Ann Zeisset, coding practice manager with the American Health Information Management Association. For instance, physical therapy (V57.1) requires the use of an additional code to describe the focus of the therapy, but that code can be sequenced anywhere in M0240, depending on your judgment of the application of other sequencing rules. Only the "code first" and slanted bracket conventions impose absolute sequencing rules, Zeisset says.

5. There is no specific limit to the number of V codes that you can use. The selection and order depend on the specific situation and the most intensive needs, says Chapel Hill, NC-based senior consultant Judy Adams with the LarsonAllen Health Care Group. For instance, V58.3 (attention to surgical dressings) would be appropriate when the nurse is visiting to provide "high-frequency wound care to a surgical wound," Adams explains. But for wound care that's just part of general surgical aftercare, V58.42 might be used, followed by codes such as V58.3 for the specific activity - in this case wound care.

Remember that coding guidelines require surgical aftercare codes to be used along with other aftercare codes "to fully identify the reason for the encounter," Adams says.

6. Insulin pumps can involve a number of V codes. V45.85 is an informative code indicating the presence of an insulin pump; V53.91 is for fitting the pump; V65.46 is for training the patient to use the pump and V58.69 is for monitoring the long-term drug use, Abraham explains.

7. Always look for the most intensive service you're providing. You may find yourself using a V code related to just PT or a V code related to both PT and nursing, Adams explains, but you still need to look at what is the most intensive service. "Intensity is measured by the highest frequency or the highest acuity," Adams advises. And remember that nursing care often is related to a diagnosis rather than a V code, she adds.

8. Beware of software glitches. If you have used a V code in M0230 instead of a case mix code, you need to put the case mix code in M0245 so you will be paid appropriately. But you also may need to put the case mix code in M0240, Adams says.

The Centers for Medicare & Medicaid Services may expect a diagnosis important enough to be in M0245 also to be a secondary diagnosis and show up on the plan of care. And many agencies have software programs that won't automatically transfer a code from M0245 to the plan of care, she notes. However, it can be even more confusing. Some software programs will reject the assessment if you put the same code in M0240 and M0245, and others require you to put some diagnosis in M0245 even if you didn't use a V code to replace a case mix code in M0230, Adam says.

"Bottom line - home health agencies need to know how their software tracks from the OASIS to the plan of care and the bill," Adams emphasizes.

9. You can use symptom codes as a last resort. If you have a patient with symptoms and the doctor has not diagnosed the cause, or isn't available to do so, codes from categories 780-89 are acceptable coding alternatives.

10. Browse through the V code chapter. Familiarizing yourself with the V code choices will help improve your accuracy, experts say.

The lifting of the prohibition against V codes "has rocked our world in the home care industry," Abraham says. But remember not every patient's situation will call for a V code, she adds.