Wiki V15.89 (high Risk Pap)

[cedwards]

We are billing for a Medicare patient who came in for a screening pap who is high risk. We do not have the info as to why the patient is high risk. When the charge was entered the coder entered it with only the V15.89 ICD-9 code. It hit an edit stating that this V15.89 code is not a primary DX for Medicare. I have always billed the V76.2 (pap screening) as the primary with the V15.89 as secondary and have never had a problem unless the MD has indicated to me the reason they are considered high risk but most of the time those codes aren't acceptable as primary either. The new coder does not feel the V76.2 and V15.89 is correct. Any advice?

 

[imjsanderson]

I agree with your new coder. You should bill V15.89 only, as long as the physician states the patient is high risk. You would not bill V76.2 and V15.89 because the patient is either one or the other. I am not sure why your edits are denying this. I bill this code with Medicare dialy.

 

[Anna Weaver]

high risk pap

Can you use V72.31 routine gyn exam for the pap? the V15.89 can't be used as first listed according to ICD-9, it's only an additional diagnosis. If the patient is high risk, it wouldn't be a screen. Will have to check a little further on this one. interesting!

 

[amjordan]

In this instance, Medicare direction for billing the G0101 and the Q0091 trump the ICD-9 coding rules. Medicare says if the patient qualifies as High Risk to use the V15.89. Most practice management systems edits are very generic, and don't recognize insurance specific rules. Some systems will allow you to create you own carrier specific edits to help in this instance.

 

[Anna Weaver]

pap

In this instance, Medicare direction for billing the G0101 and the Q0091 trump the ICD-9 coding rules. Medicare says if the patient qualifies as High Risk to use the V15.89. Most practice management systems edits are very generic, and don't recognize insurance specific rules. Some systems will allow you to create you own carrier specific edits to help in this instance.

Thanks, I'm not a biller, so I'm learning as I go. This is interesting to me. They have moved me into the office with the billers (I code the procedures and help with offices) and am learning a lot! It sounds like each carrier has their own specifications as to what is acceptable to them. Confusing!

 

[amjordan]

Thanks, I'm not a biller, so I'm learning as I go. This is interesting to me. They have moved me into the office with the billers (I code the procedures and help with offices) and am learning a lot! It sounds like each carrier has their own specifications as to what is acceptable to them. Confusing!

Anna - Yes, it gets very confusing, especially in OB/Gyn. You will find that it is very important to know what your carrier's coding and billing policies are. What is correct by CPT and ICD-9 may not necessarily be the interpretation of the carrier.

 

[Stefanie]

Anna- I would be careful with the diagnosis V15.89 for Medicare. Medicare has very specific guidelines for V15.89-High Risk. Most patient's don't qualify for a high risk diagnosis and the physician just stating the patient is high risk is not good enough. I would review you carriers LCD for high risk qualifiers and make sure the patient's documentation supports this diagnosis.

 

[rdgshorty@yahoo.com]

High Risk E&M

I have a pt that has breast cancer currently. Pt had a pap done. Dr is using the 174.9 breast cancer code for the E&M, can I still put the V15.89 on the E&M or just the Q0091 and G0101?