Pediatric Coding Alert

Reviewed on May 11, 2015
Many private payers refuse to recognize V codes V72.81 (preoperative cardiovascular examination), V72.82 (... respiratory ...) and V72.84 (... unspecified) as primary diagnoses for preoperative clearance.

To address this problem, list the diagnosis prompting the surgery rather than the V code as the primary diagnosis, recommends Donelle Holle, RN, manager of professional fee services at the University of Michigan Health System, department of pediatrics, in Ann Arbor. Joel F. Bradley, MD, FAAP, editor of Coding for Pediatrics, a member of the AAP coding and reimbursement committee and a practicing pediatrician in Clarksville, Tenn., concurs. The proper diagnosis is the one necessitating the surgery.

Because this diagnosis is likely to be serious, payers computers wont reject it. And using such a diagnosis is proper coding: After all, you would not perform the preoperative exam unless the child had the problem. Use the V code as a secondary diagnosis, showing that a preoperative examination was performed.

For example, a patient may have caries, calling for extraction of a tooth. For a child, this requires a surgical procedure with anesthesia, and therefore a preoperative clearance is necessary. List 521.0 (dental caries) as the primary diagnosis and V72.84 as the secondary diagnosis.Under ICD-10, you’ll report Z01.818, Encounter for other preprocedural examination, as your secondary diagnosis. For the dental caries primary diagnosis, the ICD-10 code can be found in the K02.- series.

In another example, a child suffers repeated ear infections. The pediatrician sends the patient to an otolaryngologist, who determines the child requires tubes. The specialist returns the patient to the pediatrician requesting that he or she perform a preoperative clearance exam. Report the service with chronic otitis media (381.x or 382.x) as the primary diagnosis and V72.84 as the secondary diagnosis.Under ICD-10, you’ll look to the H65.- and H66.- series for otitis media diagnoses.

Dental Insurance May Require V Code

If a childs dental insurance is separate from his or her medical insurance, and he or she requires dental surgery, use preoperative clearance not the dental diagnosis as the primary diagnosis. The medical insurance will not cover dental in this case, and therefore a dental diagnosis should not be billed. The only exception is if there is an abscess, in which case coverage moves from dental to medical.

When there is no dental coverage, however, report the surgical diagnosis as primary.

Chronic Condition

Some children have chronic health conditions that complicate both the surgery and the preoperative exam. According to some insurers, this is the only time [...]