Primary Care Coding Alert

Family practice coders are often confused whether they should use V codes to bill follow-up visits. Some coders say V codes accurately describe the visit; others say the original diagnosis codes should always be billed. Knowing whether to use a V code as the primary or secondary code will help family practices decrease denials.
 
When coding the diagnosis of a follow-up visit, the original diagnosis code from the previous visit does not often give the payer enough information to prove medical necessity. Coders use V codes for further explanation. "It may decrease the likelihood that the claim will be denied for lack of medical necessity,'' says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Lansdale, Pa. "It tells the whole story. It gives a more complete picture."
 
Because Medicare and private carriers do not always pay for services linked with V codes, you must determine when they will enhance payment and when they will cause denials.

Sometimes, coding a follow-up visit calls for a V code to supplement the original diagnosis code. For example, a patient who had mononucleosis comes in three months later. The patient presents with symptoms of swollen glands and a fever and is afraid she has a recurrence of mononucleosis. The physician conducts blood work and determines that the patient does not have mononucleosis but has a viral infection. Use 079.99 (unspecified viral infection) as primary and V12.09 (personal history of certain other diseases; infectious and parasitic diseases; other) as secondary. "In this case the V code indicates that the patient has a history of mononucleosis, which may help justify the medical necessity for the blood work," Falbo says.

According to the American Hospital Association, V codes can be used as the principal diagnosis "To indicate that a person with a resolving disease or injury or a chronic condition is being seen for specific aftercare, such as the removal of orthopedic pins." Often "specific aftercare" qualifies as the global period, and although the appropriate V code should be used for coding accuracy, a follow-up visit during the global period will not be reimbursed. However, a V code can be billed instead of the original diagnosis code for a follow-up visit to ensure that the condition is resolved and the patient is no longer at risk.
 
When a physician is following the course of a patient on serious therapeutic drugs, use of the V code is correct and payable. For example, a patient with attention deficit hyperactivity disorder (ADHD) has been on Ritalin for six months. He comes in for a follow-up visit so the FP can monitor how the drug is affecting him. Because the physician is monitoring the long-term effects of the drug and not the  disease, a V code can be used as the primary diagnosis code. In this case, use V58.69 (long-term [current] use of other medications, which includes high-risk medications) with the appropriate E/M code (99212-99215). The diagnosis for ADHD (314.01) should be listed as secondary.
 
Also use a V code as the primary code for a diabetic patient who comes in for a follow-up 30 days after the amputation of his right great toe. Because the patient lives in a rural area (far from the surgeon), he presents to the FP for surgical follow-up care. The physician cannot use the diagnosis of gangrene, which prompted the amputation, because the dead tissue is gone. The family practice should first code V67.09 (follow-up examination following other surgery), then V49.71 (lower limb amputation status, great toe).
 
Although some follow-up visits can be billed with a V code as the primary one, be prepared for denials when the V code is used alone. Payers often will not reimburse in these cases because they don't see the medical necessity.
 
"When a commercial carrier does not reimburse, send a letter to the medical director explaining the rational you used for coding the denied service," says Thomas Kent, CMM, CPC, MBA, principal of Kent Medical Management, a coding consulting firm based in Dunkirk, Md. "Request an explanation of their denial. If their explanation is a simple refusal to recognize V codes, ask the medical director how they want the general situation to be coded and get the answer in writing." If the payments are ever questioned, show the written support for the provider's specific coding method.

Coders should also use a V code as the primary code when billing a follow-up visit as part of the global procedure. Although FPs do not usually treat patients during the global period for major surgeries, there are some minor procedures for which they provide aftercare. For example, a patient who had a wart removal (11400) comes in for a follow-up visit to have his stitches removed. Code V58.3 (encounter for other and unspecified procedures and aftercare; attention to surgical dressings and sutures) with the appropriate E/M established patient code. Because this follow-up visit is part of the 10-day global period of the wart removal, the practice will not be reimbursed for it, but it is important to adhere to correct coding principles.
 
However, if the same patient comes in 12 days after the wart removal with an infection where the wart was, list the diagnosis code for the infection (882.0) as the primary code and V58.89 (other specified aftercare) as the secondary code. Since an infection is not considered "normal" follow-up care, it is not covered by the concept of the global period and most payers will reimburse for the visit.