Ophthalmology and Optometry Coding Alert

Make sure you know how to apply V codes

Choosing the right CPT procedure code is the first step to ensure your ophthalmologist gets paid for the work he does, but if you fail to attach the correct diagnosis code, you may be in jeopardy of receiving denials. Follow these recommendations to ensure you're properly coding patients' signs, symptoms and diagnoses.

Watch for Fourth- and Fifth-Digit Requirements

Correct coding requires that you code to the highest specificity possible. That means that your physician should assign the most precise ICD-9 code to a service. You cannot justify a service with a four-digit diagnosis code when carriers or ICD-9 requires a more specific five-digit code to describe the patient's condition.
 
"Using the fourth or fifth digit when it is required--or just when you do have that information--is an important concept to follow," says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated, she adds.

Pitfall: Just because you have to code to the highest specificity, that doesn't mean you can fill in or assume any information that isn't in the patient's medical record.

Don't Avoid Signs and Symptoms

When your ophthalmologist provides a confirmed diagnosis, you should always code that diagnosis instead of the presenting signs and symptoms. If, however, the ophthalmologist cannot document a definitive diagnosis, report the patient's signs and symptoms to support medical necessity for services the physician provided.

Pointer: Talk to your physicians about how important it is to be accurate with their terms. Tell the ophthalmologist that if he can come to a definitive conclusion about the patient's diagnosis, he needs to state this in his dictation so you may assign the best code.

Use V Codes When Applicable

Coders are often hesitant to report V codes, but sometimes they may be the most accurate descriptors of the reason for the patient's condition. Actually, you should use V codes to provide additional clinical information to an insurer, whether it's Medicare or a private carrier.

Most coders believe that V codes are only appropriate as secondary codes.

Reality: Contrary to what you might have been told in the past, you may--and, on occasion, should--report V codes as a primary diagnoses. In some instances, a V code may be the only way to be paid for a service. For example, V43.1 (Pseudophakia) may be the only diagnosis you have for a Medicare patient who has had cataract surgery, Arendt says.

"I have also used the V codes for family or personal history of certain medical conditions (diabetes, glaucoma, macular degeneration, prematurity), because the patient insisted that the visit was medically necessary due to that," Arendt adds.

Tip: Many versions of the ICD-9 manual will indicate whether you can report a V code as a primary or secondary diagnosis code using the indicators "PDx" (primary) and "SDx" (secondary) next to the code descriptor. If the code has neither a "PDx" nor an "SDx" designation, you may use that V code as either a primary or secondary diagnosis code, according to ICD-9 instructions.