Pediatric Coding Alert

Question: When a pediatrician performs a preoperative exam for a patient who is scheduled for dental cavity removal, Anthem Blue Cross denies the service. Am I submitting the claim correctly as:

• primary diagnosis--V70.3

• secondary diagnosis--521.0x

• consult code--99242?


Virginia Subscriber


Answer: Your V code selection could trigger the rejections. You should report a non-problem-related preoperative exam with V72.83 (Other specified examinations; other specified pre-operative examination), rather than using general medical exam code V70.3 (Other medical examination for administrative purposes). ICD-9 classifies preoperative exams as V72.81-V72.84. When a child requires a general medical examination to complete a camp, school or sports form, you should assign V70.3.

You are correct that you should submit a secondary diagnosis of 521.0x (Disease of hard tissues of teeth; dental caries...). This ICD-9 code appropriately represents the condition that prompted the surgery.

Reporting V72.83 as the primary diagnosis and 521.0x for the secondary diagnosis follows ICD-9 coding guidelines. Check with Anthem for other sequencing preferences, such as listing the diagnoses in the reverse order: 521.0x, V72.83.

Using the correct V code, however, may not solve your payment problems. Anthem may consider preoperative exams absent any conditions medically unnecessary and thus a noncovered service.  

Good idea: You may want to make preoperative examinations without underlying conditions elective services. Inform the patient's parent that the insurer may deny the service as medically unnecessary, in which case payment will be the parent's responsibility.
 
Alternative: If the patient has an underlying condition, such as a heart murmur, that puts her at greater risk for surgery and requires prophylactic treatment, the insurer may pay the consultation charge. In this case, you should report the diagnoses in this order:

1. underlying condition--the heart murmur diagnosis, such as 424.1 (Aortic valve disorders) for a Flint murmur or 785.2 (Symptoms involving cardiovascular system; undiagnosed cardiac murmurs) for a not-otherwise-specified murmur

2. preoperative exam--V72.83

3. surgical reason--521.0x.

Caution: To use a consult code, such as 99242 (Office consultation for a new or established patient ...), the dentist must have requested the pediatrician's opinion on the child's ability to undergo surgery. The pediatrician must render his findings and issue a written report to the dentist. Completing the premedical operative form counts as the report.