Primary Care Coding Alert

Question: Is V58.69 a secondary code?

Texas Subscriber

Answer: Yes. ICD-9 considers V58.69 (Long-term [current] use of other medications) a secondary diagnosis. The red square box containing "SDx" that appears next to V58.69 identifies V codes that can only be used as a secondary diagnosis. Thus, Medicare and many other payers may deny V58.69 when used as a primary diagnosis.

If a payer allows you to use V58.69 as the primary diagnosis, you can report it as Diagnosis 1 attached to the appropriate level office visit, such as 99212-99214 (Office or other outpatient visit for the evaluation and management of an established patient -).

Example: You could code a medication check for possible physical side effects to Ritalin for attention deficit disorder (ADD)with 9921x linked to 314.00 (Attention deficit disorder; without mention of hyperactivity) and V58.69.