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 that a preoperative clearance exam is medically necessary.

Use three diagnosis codes for preoperative exams of children with chronic conditions, the first representing the chronic condition, the second for the condition that necessitates the surgery (such as tubes or dental caries) and lastly the appropriate V code.

Some payers expect V72.81 and V72.82 to be performed by specialists cardiologists or pulmonologists, respectively while others allow the primary care physicians to perform them. Under ICD-10, you’ll report Z01.810, Encounter for preprocedural cardiovascular examination, in place of V72.81. When ICD-10 takes effect, you’ll bill Z01.811, Encounter for preprocedural respiratory examination instead of V72.82.

For example, the child may have been born with a small ventricular septal defect (VSD). When this child needs dental surgery for caries, the dentist requests a thorough preoperative evaluation to ascertain if the childs heart can withstand the anesthesia and surgery. The pediatrician performing the preoperative evaluation (at the dentists request) would list VSD (745.4) as the primary diagnosis, dental caries (521.0) as the secondary diagnosis and either V72.84 or V72.81 as the third diagnosis. Under ICD-10, the code for VSD will change to Q21.0.

In a second example, a child who will be receiving tubes may have a heart murmur, for which the otolaryngologist requests a thorough preoperative examination. Report heart murmur (785.2) as the primary diagnosis, otitis media (381.x or 382.x) as the secondary diagnosis and V72.84 or V72.81 last. When ICD-10 takes effect, you’ll report a code from the R01.- series for the heart murmur.

Alternatively, the child in the above example may have asthma. In this case, you may choose V72.82 over V72.84 and almost certainly over V72.81 depending on payer preference. List asthma (493.xx) as the primary diagnosis, otitis media (381.x or 382.x) as the secondary diagnosis and V72.82 (or possibly V72.84) as the third diagnosis.When ICD-10 takes effect, you’ll report a code from the J45.- series for asthma.

Choose the Correct Procedure Codes

There is no specific CPT code for preoperative clearance. If the surgeon requests the examination, bill a consultation code (99241-99245). To meet the criteria for a consultation, document the request and send a written report back to the requesting physician (the surgeon). You may bill a consultation on your own patient.

Because pediatricians often converse with surgeons via telephone, they must remember to document the request for the preoperative consultation the request itself can be verbal, but it must appear in the chart. The first line of the chart, on which the chief complaint is listed, should read, The child presents today at the request of Dr. ENT for a preoperative clearance consultation, or something similar.

Regardless of when the pediatrician last saw the child, choose the consultation level based on the level of service performed during the preoperative clearance exam.

If the child suffers from an underlying condition that complicates surgery, thus requiring a comprehensive exam, code a higher-level consultation code. For example, a child has a history of asthma with ongoing treatment with non-aerosolized steroids and bronchodilators. Code this consultation at a higher level than that for a child without any pre-existing problems.

A payer that rejects your claim probably does so because its computer only looks at the first diagnosis. If the computer doesnt register the other diagnoses, the payer will assume, for example, that you are consulting a patient for dental caries only. The payer will never get to the preoperative clearance exam or any underlying medical conditions, if they exist. In this case, appeal with a letter explaining the claim.

Sick and Well Visits

Instead of a consultation, pediatricians might code a sick visit (99212-99215) for preoperative clearance exams, says Richard H. Tuck, MD, FAAP, founding chair of the AAP committee on coding and reimbursement. If, for example, the child suffers a chronic condition, and there is an exacerbation of that condition, a sick visit might be appropriate. Remember, however, that a consultation code will reimburse better.If your payer stopped accepting consult codes, report the appropriate office visit code instead (99201-99215).

Some pediatricians bill preoperative clearance when they perform preventive medicine services (99381-99385 for a new patient, 99391-99395 for an established patient), because they know that the exam for preventive medicine services is at least as thorough as that for preoperative clearance. In this case, reimbursement does not increase for any extra work involved with the preoperative clearance.