Primary Care Coding Alert

Expect fewer V65.5 rejections in 2005

You dread using a V code with a worried well visit due to denial concerns, but researching payers' variations and reviewing rejections can avoid reimbursement issues.

1. Check Insurer V Code Policies

 
Even though you should use V65.5 for a "worried well," V67.x for a previous condition and V71.x for a suspected, unfound condition, payers may request alternative diagnostic coding.
 
Insurers may require the complaint in either the primary or secondary position and the V code in the other position. Not following the payer's hard-copy guidelines could result in denials.
 
Best practice: "The physician should query the payer as to its policy," says Jeffrey Linzer Sr., MD, MICP, FAAP, ICD-9-CM editorial advisory board representative.
 
Example: Parents bring their child into your office because they were worried that he takes too long between breaths. The parents, however, had just misinterpreted normal infant respiratory pattern.
 
ICD-9 guidelines: You would code V71.89 to show an evaluation of a suspected, not found condition.
 
Variation: "The payer may want you to code for apnea (786.03) as the primary complaint and V71.89 as a secondary code to show that no problem was found,"  Linzer says.
 
Insurers may also have different requirements for reporting resolved conditions. "As part of the HIPAA transaction code set, all payers are supposed to follow ICD-9-CM Official Guidelines," Linzer says. But in the case of an ear follow-up exam, an insurer "may want you to indicate the complaint as the primary diagnosis then use the V code for condition not found."
 
Bottom line: You would code 381.x (Nonsuppurative otitis media and Eustachian tube disorders) with V67.59 (Follow-up exam; other) based on the payer's guidelines, instead of V67.59 based on ICD-9 coding principles.

2. Look at Rejection Rates

After reviewing your major insurers' V code sequencing policies, check your reimbursement rates.
 
You may be surprised at what you find. Payers generally accept V code diagnoses in the primary position, says Jean S. Oglevee, CPC, coding specialist at Family Medicine Centreville in Centreville, Va. "We billed 21 such claims in nine months" and all insurers except one paid.
 
Good news: If you have been receiving numerous primary V code rejections, you could see that figure decline in the next few months. Because publishers of the ICD-9 coding manual indicated you should use V65.5 as a secondary diagnosis, insurers often turned the denotation into coding policy, says Victoria S. Jackson, CEO of Omni Management in Lake Forest, Calif. The ICD-9 2005 manual no longer contains the secondary diagnosis indicator with V65.5. "We're now getting claims containing only V65.5 paid."