Orthopedic Coding Alert

Talking with a patient (or his or her surrogate) with undiagnosed, early-stage Alzheimers disease or dementia about the risks and benefits of a hip replacement might take extra physician time. And the physician carefully must document the amount of time spent with the patient in counseling and coordinating care to code for the allowable evaluation and management (E/M) service. (See related article on page 27.) But coding should not stop there.

The supplementary ICD-9 code V40.9 (unspecified mental or behavioral problem) should be recorded in addition to the relevant musculoskeletal diagnosis for the patient, such as osteoarthrosis of the hip (e.g., 715.15, osteoarthrosis, localized, primary, pelvic region and thigh).

V codes, although not often used as primary diagnosis codes (and some cannot be used for a primary diagnosis), are important. Using V codes allows a practice to monitor services rendered to patients for studies, statistics and also as a mechanism for defending requests to managed-care companies for additional reimbursement for more difficult cases, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

If you have not documented difficult cases by way of a diagnosis code, continues Callaway-Stradley, it is difficult, if not impossible, to present useful information to another party.

Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., a medical billing firm in Broomfield, Colo., agrees and says, When appropriate, use [V codes]. Page says some of the codes are particularly useful in supporting a diagnosis. She gives V58.69 (long-term [current] use of other medications high-risk medications) as an example.

But Page cautions against using V codes indiscriminately. I would not use them unless they directly related to the visit, she says.

Noting an acquired absence of a breast (V45.71) would be unnecessary if the patient arrived for treatment of a fractured middle finger (816.11, open fracture of middle phalanx). But reporting that a patient is dependent on a respirator (V46.1) is useful if it bears on a medical decision, such as treating a closed fracture of the shaft of the humerus (812.21). In other words, it might help explain the choice of closed manipulation (24505, closed treatment of humeral shaft fracture; with manipulation) instead of a surgical intervention (e.g., 24515, open treatment of humeral shaft fracture with plate/screws, with or without cerclage).

Health Status vs. Aftercare

Codes in the series V40-V49 (persons with a condition influencing their health status) and V51-V59 (persons encountering health services for specific procedures and aftercare) are particularly relevant to orthopedic practices.

Health Status: Many codes in the V40-V49 series document conditions that grow more common with age, such as problems with sight (V41.0) and problems with hearing (V41.2). Physicians serving an elderly population in an outpatient setting or at a skilled nursing facility will find the codes helpful in completely documenting the complexity (duration) of their encounters with patients.

Aftercare: Because codes in the V51-V59 series include aftercare, an orthopedist gives a robust picture of interaction with a patient with the use of a V code. For example, to code the change, checking, or removal of Kirschner wire or plaster cast or external splint or other external fixation or traction device, orthopedists should report code V54.8 (other orthopedic aftercare).

Whether to report V codes before or after the primary diagnosis code(s) depends on the agreement between the payer and the entity submitting the claim, according to Nancy Klinkhamer, RRA, a supervisor and coding abstractor at a medical facility in the midwest. Klinkhamer notes that although V codes are generally more applicable in outpatient settings, they are used where appropriateand relatively oftenin hospitals.

Reasons for Using V Codes

Callaway-Stradley says, Insurance companies are beginning to watch diagnosis coding very carefully. If the patient is only being seen for prosthesis follow-up (V52.0-
V52.9), which may have some frequency limits with insurance companies, then the insurer would consider it inappropriate to list another, payable diagnosis and not report the V code.

In other words, the insurer wants an accurate tally on the follow-up care visits, and the insurer does not want the cumulative sum obscured by another diagnosis. Thus, report the new diagnosis and the V code for the follow-up care. It is good coding, and it will prevent problems.

V codes do not help just the insurer. V codes, when used in conjunction with other diagnoses, can help to support a question of medical necessity on appeal, says Callaway-Stradley. For example, a patient with knee pain who is also being seen for his annual check of a hip prosthesis would probably require a higher level of E/M service. With insurers scrutinizing high levels of E/M service, the information about both facets of the encounter is more likely to garner reimbursement at the proper level.