Part B Insider (Multispecialty) Coding Alert

Explore your options to indicate follow-up exams

Don't be surprised when you see a V code listed first on your neurosurgeon's claims.

You can use V codes as the primary diagnosis when your neurosurgeons provide follow-up care for a patient with past injuries and/or treatment.

Scenario #1: A patient suffers a traumatic spinal fracture due to a fall. "If a patient returns for follow-up care after a [spinal] fracture, you shouldn't report the fracture code again," explains Susan Vogelberger, CPC, business office coordinator for the Orthopedic Surgery Center at Beeghly Medical Park in Ohio.

In other words, if the spinal fracture is no longer an acute condition (that is, the fracture has healed following physician care), you are incorrect to use a fracture code as a primary diagnosis. Rather, you should turn to V54.17 (Aftercare for healing traumatic fracture of vertebrae).

Pitfall: Coders and physicians often make the mistake of overlooking V codes for a patient whose disease process is no longer active, notes Jean Acevedo, LHRM, CPC, CHC, senior consultant with Acevedo Consulting Incorporated in Delray Beach, FL.

Scenario #2: For instance, a female patient who has successfully undergone surgery for removal of a brain neoplasm visits the neurosurgeon for evaluation of wound and neurological deficits.

Rather than report an acute diagnosis of brain neoplasm (for instance, 191.1, Malignant neoplasm of brain, frontal lobe)--which is inaccurate--you should select V58.42 (Aftercare following surgery for neoplasm) to reflect that the check-up is for a condition that is no longer acute. "Aftercare visit codes cover situations where the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase," according to ICD-9 guidelines.

Another use: You should also employ V codes for "continuing surveillance following completed treatment of a disease," according to the ICD-9 guidelines, but don't confuse them with aftercare codes. Example: After a year without complications, the patient in Scenario #2 returns to see the surgeon for evaluation of any possible recurrence. In this case, you should report V67.09 (Follow-up examination, following other surgery).