Pulmonology Coding Alert

Pulmonologists frequently see patients suffering from chronic lung conditions that can potentially affect other organs or systems. For example, emphysema and COPD can affect the heart, and certain medications used to treat asthma may damage the liver. Consequently, routine office visits for such patients involve more than just a monitoring of the chronic pulmonary condition. The physician must also check the heart or liver as a precautionary measure. These additional examinations complicate the coding of office visits because they are needed for the well-being of the patient even though no symptoms point to a specific problem necessitating the screening procedure. To ensure prompt and complete reimbursement from both Medicare and private carriers for these procedures, coders should use the appropriate V code.

Preventive or Not?

As Carol Pohlig, RN, CPC, a reimbursement analyst for the office of clinical documentation in the department of medicine at the University of Pennsylvania, points out, "To the clinical world these procedures may appear to be preventive, but to the coding world they are not. The confusion is furthered when the physician refers to one of these procedures as a screening. Often, the coder does not realize what has been done and why." 

She goes on to explain that the difference between the two perceptions lies in the intent behind the test, examination or procedure. The reason, for example, for giving an emphysema patient an EKG during a routine physical is different from administering the same test to a patient not suffering from the disease. For both there may be no clinical symptoms suggesting a heart problem. But unlike using an EKG as part of a physical for an insurance policy or as part of a pre-employment physical, for instance, the procedure is medically indicated for the emphysema patient because of the pulmonary disease.  Therefore, in the second situation, the EKG is not seen as preventive; rather, it is necessitated because the patient is at-risk for heart complications, and an EKG will reveal problems before physical symptoms manifest resulting in quicker and more effective treatment. Mary Jean Sage, CMA-AC, principal consultant with Sage Associates in Arroyo Grande, Calif., explains, "An EKG in this situation becomes an 'at-risk' screen, not a preventive one." It is, therefore, coded using V codes.

According to the ICD-9 2001 manual, V codes are provided to deal with occasions when circumstances other than a disease or injury classifiable to categories 001-999 are recorded as diagnoses or problems. This can arise in three ways:

1. When a person who is not currently sick encounters the health services for some specific purpose, such as to act as a donor of an organ or tissue, to receive proper prophylactic vaccination, or to discuss a problem which is not a disease or injury. This is rare among hospital inpatients, but will be more common in hospital outpatients and patients of family practitioners, health clinics, etc. 

2. When a person with a known disease or injury, whether it is current or resolving, encounters the healthcare system for a specific treatment of that disease or injury.

3. When a circumstance or problem influences the person's health status but is not a current illness or injury. Such factors may be elicited during population surveys, when the person may or may not be currently sick, or be recorded as an additional factor to be kept in mind when the person is receiving care for some current illness or injury classifiable to categories 001-999.
    
For example, a 53-year old woman with chronic emphysema who receives an EKG during a routine physical falls into the third category. Since her pulmonary condition indicates the potential for cardiac complications, it is important to monitor the heart. The EKG would be coded using V71.7 (observation and evaluation for suspected conditions not found; observation for suspected cardiovascular disease) or V81.2 (special screening for cardiovascular, respiratory, and genitourinary diseases; other and unspecified cardiovascular conditions).

Since this test was the result of the emphysema, V71.7 or V81.2, as with most V codes, would be used as a secondary diagnosis to "paint a clinical picture" of the patient's condition. Emphysema (492) would be the primary diagnosis code to assign to the EKG.

Use of V Codes for Medication

A similar coding challenge exists for asthma patients taking medication such as theophylline, which can potentially cause liver damage. For example, a 23-year-old male taking this drug presents himself to the pulmonologist's for a routine exam. In addition to the procedures necessitated by the asthma, the physician palpitates his liver and performs a blood test, checking for signs of liver damage. Even though the young man exhibits no symptoms such as jaundice, weight loss or decreased appetite, this type of exam would be indicated because of the medication involved, and would be coded using V58.69 (long-term [current] use of other medications). As with the EKG example, this V code would not be used by itself. The reason for the "high-risk" medication -- asthma -- would also be indicated and reported. 

Coding for "At-Risk" Patients

V codes are also used when certain procedures are performed because personal or family medical history indicates that a patient is at risk for a particular medical condition even though he or she currently exhibits no symptoms. For a pulmonologist these situations usually involve a history of cancer or other chronic diseases of the respiratory system such as asthma. Procedures used by the physician to monitor the pulmonary organs as a result of a personal history of cancer would be coded using V10.11 (personal history of malignant neoplasm; bronchus and lung), V10.12 (... trachea), and V10.2x (... other respiratory and intrathoracic organs). A family history of such cancers indicating these procedures would be coded using V16.1 (family history of malignant neoplasm; trachea, bronchus, and lung) and V16.2 (... other respiratory and intrathoracic organ). 

A personal or family history of cancer of the trachea, bronchus and lungs, must be matched with the appropriate ICD-9 code 162 (malignant neoplasm of the trachea, bronchus, and lung), while a history of malignancy in other respiratory and intrathoracic organs must be classifiable to 160 (malignant neoplasm of nasal cavities, middle ear, and accessory sinuses); 161 (malignant neoplasm of larynx); 163 (malignant neoplasm of pleura); 164 (malignant neoplasm of thymus, heart, and mediastinum); or 165 (malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs).

Personal and family history of other diseases of the respiratory system would be coded using V12.6 (personal history of certain other diseases; diseases of respiratory system), V17.5 (family history of certain chronic disabling diseases; asthma), or V17.6 (... other chronic respiratory conditions). 

For example, a 35-year-old man was successfully treated for cancer of the right bronchus (162). His pulmonologist routinely performs the appropriate examination, checking for any indications of a recurring malignancy in the bronchial tube. In the absence of any signs, symptoms or patient complaints, this situation would be coded using V10.11 because the reason for this exam is not preventive (i.e., an annual physical exam); rather, it is indicated because the patient's history of cancer makes him potentially at risk for a repeat occurrence.

Similarly, a 50-year-old woman with a family history of asthma routinely visits her pulmonologist's office for an examination. Given her family history, monitoring her lungs is indicated as a precautionary measure even though she exhibits no symptoms of the disease. As a result these visits are coded as V17.5. The history of asthma in her family makes her routine visits more complex, a situation that the V code indicates. 

V Codes Can Signify Disease Carriers

One final use of V codes involves exams of patients who are carriers or suspected carriers of infectious bacterial diseases, specifically streptococcus, meningococcal or staphylococcal disease. The procedure used to test for these diseases would be coded using V02.51 (carrier or suspected carrier of infectious diseases; other specified bacterial diseases; Group B streptococcus), V02.52 (... other streptococcus) and V02.59 (... meningococcal or staphylococcal). 

Ensure Reimbursement

While practices submit claims for procedures using V codes, they have problems receiving reimbursement, both with Medicare and private carriers, according to Sage. She explains, "These codes lack specifics, making it easy for them to be rejected. A good example involves V71.7 (observation and evaluation for suspected conditions not found; observation for suspected cardiovascular disease). Since the potential cardiovascular disease is not specifically named nor is one found during the examination, it is easy for an insurance company to reject the claim." 

Sage suggests using the diagnosis field on the HCFA 1500 claim form to bring attention to the fact that a V code is being used as a secondary diagnosis. The use of multiple codes accurately denotes the patient's condition, resulting in efficient reimbursement. This careful documentation is especially important for private insurance companies, because sometimes they do not understand how or why the procedure was used. Therefore, complete explanations and documentation are vital for reimbursement. 

Recently, Medicare has become more amenable to reimbursing for such procedures. However, since there is significant latitude from carrier to carrier, coders should check their LMRP guidelines when reporting V codes. Medicare's more generous policy is good news for practices when filing with private carriers because its acceptance can be used as leverage for obtaining reimbursement from private carriers. As a final word of advice, Sage suggests being tenacious in appealing when faced with a rejection for a V code. Since the appeal process varies from carrier to carrier, they should be consulted for the exact process. In general, the first step involves learning the specific reason for the denial so that appropriate documentation can be submitted.