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llong@rhcc.com

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We saw a patient who had a lung lesion and a skull lesion. Feeling that probably something is going on and looking for something to biopsy... we ordered CT Brain, neck, chest. I think the neck would not pass, so we used lung/skull lesion and V717.1. However I was dinged from our quality department on using V71.1.
Observation codes are to be used if there are no signs or symptoms and I think nodules and lesions are signs and symptoms. And it is not a stand alone code. Here is what coding guidelines say: “V67.00, V67.1, V67.2, and V71.1 are non-specific ICD-9 codes, which require an additional ICD-9-CM code to specify the disease entity treated.”
I thought you could use V71.1 when you were suspicious that cancer was involved?
Please help me understand this code.
 
V71.1 is for a suspected malignant neoplasm not found. You must use the heading in the V71 category as part of the descriptor for each code in the category, this is not for a suspicion of malignancy but for when there was a suspicion that was not found to be a malignancy. V71 codes are all first listed only allowed. I am not sure where you are reading the coding guideline you pulled, but V71 codes are not non specific ICD-9 codes and do not require an additional code. You ususally use a secondary with the V71.1 to show what the finding was such a benign neoplasm,but you must have a path report that shows no malignancy to use V71.1
 
V71.1 is principal dx only but it is rarely used and a circumstance that calls for it would kinda tricky. You would use it for a patient being observed for a suspected condition, without signs or symptoms, that has been ruled out (i.e mitchellde's reference to having this documented via path).

With the information you shared, my best advice would be to not use the V71.1 at all. Your patient is not without signs or symptoms, he/she has lesions. I suspect the physicians documentation would have additional signs and/or symptoms you could reference.
 
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