Primary Care Coding Alert

Our guidelines spell out the requirements for aftercare, V codes

What should you do when you see a V code listed first on your family physician's claims? This is just one of the coding questions that you may encounter when dealing with ICD-9 coding.

We-ve compiled three coding scenarios and the corresponding solutions to help you overcome these common diagnosis coding challenges.

Report All Documented Diagnoses

Snag 1: A physician dictates -Primary Diagnosis: Sprained Rotator Cuff (840.4)- in his documentation for a shoulder injection (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]), but later in the body of the documentation, the FP also notes that the patient has adhesive capsulitis of the shoulder (726.0).

The coder researches the payer's policy on 20610 and finds that 840.4 (Sprains and strains of shoulder and upper arm; rotator cuff [capsule]) is not a covered diagnosis for 20610, but 726.0 (Adhesive capsulitis of shoulder) is payable.

Coders are routinely taught to list the physician's primary diagnosis as the ICD-9 code on the claim form. Can this coder use adhesive capsulitis as the diagnosis on the physician's claim, or must she stick with the rotator cuff sprain?

Solution: -As long as it is documented, you are permitted to choose whichever diagnosis supports the procedure,- says Susan Vogelberger, CPC, CPC-H, CMBS, owner and president of Healthcare Consulting & Coding Education LLC in Boardman, Ohio.

-You can even choose the diagnosis from the body of the documentation if what's listed at the top is a non-allowed diagnosis,- she says. But it would be incorrect to use a diagnosis code that the physician did not document but gets the claim paid, she says.

Why would the physician list the primary diagnosis as a rotator cuff sprain, even if he performed the injection for the adhesive capsulitis?

-Often the doctors are not aware of the local coverage decisions, etc., so they just list the diagnoses in whatever order comes to mind,- Vogelberger says. -It's the coder's job to find the correct diagnosis to support a claim based on the medical necessity.-

Bottom line: The physician may list the primary diagnosis using any of the patient's conditions, but that doesn't mean you have to list that ICD-9 code on your claim. If he dictates another, payable diagnosis, you should list that instead.

In our example above, the coder should report 726.0 followed by 840.4 as her diagnoses.

Go Ahead: List V Codes as Primary Diagnoses

Snag 2: A patient has a 2.0-cm laceration on her hand, which an emergency department physician repaired in the ED. The emergency physician billed for the surgical repair with 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less). The patient presents to your practice and the FP removes the sutures. He reports 99213 for the service. Should you list the laceration ICD-9 code as your diagnosis for the suture removal visit?

Solution: Because the patient no longer has a laceration, you should not report 882.x (Open wound of hand except finger[s] alone) as your primary diagnosis for the visit. Instead, you should report V58.32 (Encounter for removal of sutures), which is a new code effective Oct. 1.

In other words, if the laceration is no longer an acute condition, you are incorrect to report code 882.x as a primary diagnosis.

Pitfall: Coders and physicians often make the mistake of overlooking V codes for a patient whose disease process is no longer active, says Jean Acevedo, LHRM, CPC, CHC, senior consultant with Acevedo Consulting Inc. in Delray Beach, Fla.

According to the ICD-9-CM Official Guidelines for Coding and Reporting, -Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.-

Therefore, you can report these V codes as your primary diagnoses when the physician must see the patient for continued care due to his previous condition or ongoing disease.
 
Use Treating Diagnosis for PT

Snag 3: You just hired a physical therapist, and your coder noticed that very few of the PT policies list the diagnosis codes that the FP and PT are treating as -payable.- Why?

Solution: Physical therapists and their coders often confuse the referring physician's medical diagnosis with the therapy treatment diagnosis, and undue denials result. To solve this problem, always ask yourself this question: -What is the patient's specific condition or problem that the PT is treating with this therapy service?- You should never assume that the diagnosis on the physician's request form is the relevant diagnosis for the therapy that the PT rendered.
 
For example: A patient requires therapy for gait disturbance (781.2) due to osteoarthritis (715.xx). The family physician's request states, -evaluate and treat,- but it also lists the medical diagnosis of osteoarthritis that the physician has been treating. The PT spends 30 minutes performing gait-training exercises, so you report two units of 97116 (Therapeutic procedure, one or more areas, each 15 minutes; gait training [includes stair climbing]). Then you erroneously list osteoarthritis code 715.xx as the pri-mary diagnosis to justify the therapy's medical necessity.

Right way: You should report gait-disturbance code 781.2 as the specific diagnosis the PT is treating with therapy. Most payers want to see a specific -treatment diagnosis- as the primary ICD-9 code on therapy claims. If you list osteoarthritis as the primary diagnosis, chances are the carrier will deny your claim. This explains why your local coverage determinations (LCDs) don't always list the physician's diagnosis on the PT guidelines.

Even if you do collect payment with an incorrect ICD-9 code, you risk problems with payment down the line. Medicare, private carriers and other fiscal intermediaries have PT policies that list specific frequency limitations and other coverage guidelines for every diagnosis, and you may find that your patient is eligible for far less coverage than he needs if you-re reporting the wrong diagnosis.