Primary Care Coding Alert

Question: After I used V04.81 for a flu-shot diagnosis, Medicare denied all the claims based on a nonregistered diagnosis code. What diagnosis code should I assign?

New Jersey Subscriber

Answer: As of Oct. 1, 2003, when the 2004 ICD-9 codes became effective, V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases; influenza) is the correct code. But some payers may not update their systems until the beginning of the year or up to six months later.

For instance, Medicare permits carriers a 90-day grace period or until Jan. 1 to update their system, according to Program Memorandum Transmittal AB-03-104 available at www.cms.hhs.gov/manuals/pm_trans/AB03104.pdf. During the interim period, CMS doesn't specify whether carriers should accept both V04.8 (... influenza) and V04.81. Instead the memo states, "New ICD-9-CM codes can render some of the presently covered codes inappropriate." CMS then notes the interim timeframe and the changes that Medicare is making, including "removing code V04.8 and replacing it with V04.81." CMS concludes the explanation with, "we will not actually be removing the codes from the edit module until the January 2004 release." The statement leaves a question as to how carriers should handle the interim period.
 
Several carrier policies, such as Veritus (Pennsylvania) and Missouri Medicare, include the same dubious explanation. But National Heritage Insurance Company's (Medicare Part B carrier for California and New England) local medical review policy clearly states that during the 90-day grace period the carrier will accept both the existing and current ICD-9 codes. After Jan. 1, NHIC will accept only the 2004 ICD-9 code. To view NHIC's LMRP, visit www.medicarenhic.com/articles/ncdupdate_0803.htm.

Typically, grace periods imply that payers will accept both codes. But if the insurer hasn't updated its system, automatic edits will throw out the revised code. Therefore, you should contact your carrier and inform them that V04.81 is the new code to use. In addition, you should appeal any denials that you receive with a copy of the page from the 2004 ICD-9 book showing that V04.8 requires a fifth digit.