Oncology & Hematology Coding Alert

Question: Our oncologist saw a patient for a bladder tumor follow-up. The payer denied our claim that listed 99213 and V10.51 (Personal history of malignant neoplasm; urinary organs; bladder). Should I have coded this differently?


California Subscriber


Answer: Your payer may have denied your claim for two reasons. First, to report 99213 (Office or other outpatient visit ... established patient), your oncologist must meet two of three components: expanded problem-focused history and examination, and low-complexity medical decision-making. Make sure the medical documentation supports this.

Linking a secondary ICD-9 code (V10.51) may also have caused the denial. If the patient meets the criteria for a -history of- V code, ICD-9 official guidelines require you to use this as the primary code.

The criteria: Use a category V10 code (Personal history of malignant neoplasm) when the patient's malignancy was previously excised or eradicated and the physician no longer directs treatment to that site and evidence of an existing primary malignancy is absent. If the physician documents an extension, invasion, or metastasis to another site, code a secondary malignant neoplasm to that site. You may report the secondary malignancy as the principal diagnosis and the V10 code as a second diagnosis.

If the primary tumor still exists, you should report this as the primary diagnosis code instead. For example, if the patient has bladder cancer, list (188.x, Malignant neoplasm of bladder).
 
Follow these criteria for using V codes:

- Link a V code to procedures for patients who require services such as a prophylactic vaccine.

- Use V codes when reporting chemotherapy treatments.

-  Report a V code as an additional factor during treatment, such as a personal history code.

You should also check the follow-up visits- frequency and timing. Payers consider follow-up visits within 90 days of radiation therapy included in the radiation therapy services.

The answers for You Be the Coder and Reader Questions were reviewed by Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president, AAPC National Advisory Board.