Oncology & Hematology Coding Alert

Code V58.1 is perhaps the most common V code used by oncology practices. It looks like a logical primary diagnosis code to describe an encounter with a cancer patient being treated with chemotherapy. However, failing to use the appropriate malignant neoplasm code (e.g., 140-208) may result in denied claims or unfavorable audits because examiners are not able to tell exactly why the patient was being treated in the first place.

Hofbeck says V58.1 is a perfectly fine code to help describe the medical necessity of a patient visit for chemotherapy treatment, but it should be used as the secondary diagnosis code. Instead, the primary diagnosis code should describe the cancer that requires chemotherapy. For example, 174.0-174.9 (Breast cancer) should be listed as the primary diagnosis code to describe the medical necessity for breast cancer chemotherapy, and V58.1 should be listed as a secondary diagnosis code.

V codes are supplementary codes intended to add more detail to general diagnosis codes. One of the few exceptions are screenings, says Paula Stinecipher, president and co-founder of AlphaQuest, LLC, a coding consulting firm in Atlanta. However, screenings are usually performed by primary care physicians, not oncologists.

V codes explain when circumstances other than a disease or injury are why the patient is being treated. Oncology practices should use V codes mainly in three circumstances (as outlined in the ICD-9 manual):

1. When 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. When a person with a known disease or injury, whether it is current or resolving, encounters the healthcare system for a specific treatment of that disease

3. When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury. Such factors may be elicited during population surveys, when a person may or may not be currently sick, or be recorded as an additional factor to be borne in mind when the person is receiving care for some current illness or injury classifiable to HCPCS categories 001-999.

V58.1 As the Primary Dx Code

A common procedure in oncology is the administration of epoetin alfa (Q0136), which is used to combat chemotherapy-induced anemia. Some carriers require that V58.1 be reported as the primary diagnosis and 285.8 (Other specified anemias) or 285.9 (Anemia, unspecified) as the secondary diagnosis code for epoetin alfa administration. Because coding for the administration of epoetin alfa is payer-specific, oncology practices should check with their individual carriers before submitting a claim.

Codes for family history of neoplasm (V16.0-V16.9) are another exception when a V code can be used as a primary diagnosis code. These codes describe specific historical malignancies within a patient's family, and can be used as a primary diagnosis when there is no confirmed cancer diagnosis.

For example, a patient with a family history of breast cancer comes in for an office visit and mammogram. This may be coded using V16.0 as the primary diagnosis code because it proves medical necessity for the mammogram, and, without a proven diagnosis of breast cancer, a code from the 174.0-174.9 series cannot be used.

The personal history V codes are generally frowned upon as a primary diagnosis because once a patient has a confirmed cancer diagnosis, he or she is never considered cancer-free. So, if a patient with a history of cancer comes in for a follow-up visit, the original neoplasm code should be used as the primary diagnosis code.