Pathology/Lab Coding Alert

Watch coverage rules for medical necessity -- or you could end up with denials

Starting Oct. 1, ICD-9 gives labs new -health status- V codes to indicate the need for certain tests. But you-ll have to pay attention to laboratory National Coverage Determinations (NCDs) and other coding rules to make sure using these codes results in payment -- not denials.

For a list of the new history/genetic codes, see -Want to Show Family History/Genetic Carrier Status? Do This- in this issue..

V18.5x Aids Vigilance for Colon Cancer

A family history of colon polyps might prompt a physician to order a fecal occult blood test (FOBT) (82270-82274) or screening colonoscopy with greater frequency or at younger ages than a patient without a family history. That's why new ICD-9 codes V18.51 (Family history of colonic polyps) and V18.59 (Family history of other digestive disorders) will be useful to physicians trying to explain why they-re ordering certain tests.

Having a family member diagnosed with colon polyps or cancer of the large intestine indicates an increased risk for colon cancer. -We haven't had a lot of great ways to describe this in the past, and these new V codes are going to be a great help,- says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, coding manager for the University of Washington's physician group in Seattle.

Genetic Testing Gets a Boost

New and revised V codes for procreative management and genetic screening are also part of the latest ICD-9 update.

Use the V26.3x codes when physicians order genetic testing for males or females as part of procreative management:

- V26.31 -- Testing of female for genetic disease carrier status

- V26.32 -- Other genetic testing of female

- V26.34 -- Testing of male for genetic disease carrier status

- V26.35 -- Encounter for testing of male partner of habitual aborter

- V26.39 -- Other genetic testing of male.

Special case: You should not use these codes if a patient undergoes genetic screening not associated with procreative management. ICD-9 adds a new subcategory (V82.7x, Genetic screening) with two new codes as a parallel to the V26.3 codes when a person undergoes genetic tests unrelated to managing reproduction:

- V82.71 -- Screening for genetic disease carrier status

- V82.79 -- Other genetic screening.

For example: A physician might order cystic fibrosis screening (83890-83914, Molecular diagnostics) for a patient with a family history of the disease. Selecting the proper V code as the reason for the test will depend on whether the test is for procreative management for a male or female -- or if the genetic screening is for another reason. Depending on these circumstances, you would code the reason for the test as V26.31, V26.34 or V82.71.

NCDs Say -Not Covered-

If a patient is at increased risk for disease because of a family history, the physician might order certain lab tests in the absence of symptoms. But updated NCD rules, effective Oct. 1, add V18.51, V18.59, V82.71 and V82.79 to the list of denied ICD-9 codes for all NCDs. That means you can't use these family-history and genetic-screening codes alone to indicate medical necessity for any tests listed in the NCDs.

Here's why: The NCD coding policy manual includes a list of codes that are never covered when given as the primary reason for a test. According to the manual, a test ordered with these codes is not payable -in most instances because it is performed for screening purposes.- Except for specific screening tests authorized by statute, Medicare does not cover screening tests that physicians order -in the absence of signs, symptoms, complaints or personal history of disease or injury.-

Don't miss: Codes V18.51 and V18.59 join other family-history codes V16-V19 on the list of noncovered codes. Similarly, codes V82.71 and V82.79 are part of the other special screening codes V73-V82 that are on the CMS denied-code list. 

Scrutinize Secondary Diagnosis -- Especially for Inpatients

NCDs aren't the only guidelines that tell you when you should -- or shouldn-t -- use certain V codes as a primary diagnosis for testing. You-ll also find information in ICD-9 coding guidelines and Medicare's -unacceptable principal diagnosis- edits. If you-re confused by guidance that seems to conflict, you-re not alone.

Myth: You can never use V codes from Medicare's -unacceptable principal diagnosis- edit list as a primary diagnosis.

Reality: This edit list applies for inpatient Medicare coding only, says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG -- Children's Healthcare of Atlanta at Egleston.

Medicare limits many V codes to secondary status for inpatient coding because most V codes do not describe the patient's current illness or injury -- which is almost certainly the reason for inpatient status.

Exception: Although new ICD-9 codes V18.51-V18.59, V26.31-V26.39 and V82.71-V82.79 are on Medicare's -unacceptable principal diagnosis- list, you can still use the codes as the primary diagnosis, when appropriate, in outpatient or non-hospital patient settings.

In fact: ICD-9 Official Guidelines for Coding and Reporting lists these codes as V codes -which may be either principal/first-listed or additional codes.-

Caution: You should not use V codes as the principal/first-listed diagnosis if the ICD-9 guidelines list them as -additional only- codes. The ICD-9 manual lists these with an -SDx- indicator, meaning that you should use the code only as a secondary diagnosis.