Radiology Coding Alert

The observation code may bring in over $160, but it isn't always appropriate

Although V71.89 appears as a payable diagnosis on scores of local medical review policies, you shouldn't simply list it on every radiology claim that lacks a reimbursable diagnosis.

You should report ICD-9 V71.89 (Observation and evaluation for other specified suspected conditions; other specified suspected conditions) only if the ordering physician requests a screening for a condition that no other ICD-9 Code describes.
  
V71.89 Shouldn't Replace Signs and Symptoms

The problem: Many radiology practices have denials similar to the following scenario, which a subscriber submitted to Radiology Coding Alert :

"Our radiology group has faced denials when we perform a radiology procedure that results in negative findings. We submit the claim with the signs and symptoms, but the payers deny the claims. Should we report V71.89 for these claims?"

The reality: "If the radiology practice doesn't have medical necessity using the signs and symptoms, V71.89 probably won't help," says Jeff Fulkerson, BA, CPC, CMC, certified coder for the department of radiology at The Emory Clinic in Atlanta. "The patient must have had medical necessity for the procedure, or the ordering physician wouldn't have ordered the test. If the tests you perform are all negative, you should report the signs and symptoms."

Because the Balanced Budget Act of 1997 requires all referring physicians to supply signs and symptoms that explain why the radiology order is medically necessary, don't accept a physician order that doesn't list signs and symptoms or a definitive diagnosis.

Keep Your ABNs at Close Reach

But what if the signs and symptoms that the physician documents don't match those listed on the local medical review policy (LMRP) for the procedure? "In this case, when the patient comes in for the service, take her aside and ask her to sign a waiver of liability," (also known as an advance beneficiary notice, or ABN), Fulkerson says. You should also append modifier -GA (Waiver of liability statement on file) to the claim. "This modifier alerts the carrier that we have an ABN on file and have reason to believe that they will deny coverage for the service."

Good idea: "If the study results in a negative finding and the symptoms aren't on the LMRP, the ABN allows us to bill the patient for any balance left after the carrier has processed and denied the claim," Fulkerson says.

When in Doubt, Call the Referring Physician

If your LMRP doesn't publish a list of payable signs and symptoms, you can use common sense at times because the symptoms that the ordering physician documents may not support medical necessity, says Carrie Caldewey, RCC, CPC, office manager at Redwood Regional Medical Group in Santa Rosa, Calif. "For example, an abdominal pain diagnosis won't support medical necessity for a lumbar spine x-ray," she says.

Tip: "Rather than simply reporting V71.89, which often goes unpaid, I would either return the reports to the ordering physician for more information, request a copy of the referral form from the medical record to determine whether any additional signs or symptoms were given, or call the referring physician's office for more information," Caldewey says.

You can also obtain the patient's clinical history (including signs and symptoms) directly from the patient upon scheduling, reception, or during the examination.  You can use such clinical information to support the exam's medical necessity, even if the referring physician doesn't provide it.
 
So When Is V71.89 Appropriate?

Not every radiology claim without definitive findings warrants V71.89, but you can report this code if you screen for a problem that no other diagnosis codes describe. According to the American Hospital Association's April 2003 Coding Clinic for ICD-9-CM, V71.89 applies to the following scenario: "A week-old premature infant, who was on an apnea monitor, was brought to the emergency department because the equipment continued to alert. On examination, no problem was found with the baby. The problem turned out to be a malfunction with the monitor."

Why? Coding Clinic reasons that because no other ICD-9 codes describe malfunctioning apnea monitors, V71.89 is the appropriate choice.

You May Still Have to List Symptoms

Several carriers list V71.89 as a payable diagnosis for bone density studies (76070-76078), chest x-rays (71010-71035) and diagnostic mammography (76090-76091), but not every payer abides by these guidelines, and some place caveats on coverage. Blue Cross and Blue Shield of Kansas, for example, allows V71.89 on claims for hemodialysis access duplex scans (93990) but states, "If abnormal function is strongly suspected but not found, use V71.89 and list abnormal signs or symptoms." Even in these cases, however, other ICD-9 codes associated with inadequate dialysis function and worsening renal failure may apply.

Warning: Because 93990 (Duplex scan of hemodialysis access [including arterial inflow, body of access and venous outflow]) reimburses more than $160, coders might be tempted to misuse V71.89 -- and that's why carriers want to see a list of the signs and symptoms that warrant the scan. Even if the symptoms aren't payable, the insurers keep track of why you report V71.89, so don't abuse it.