Posted on June 30, 2008
ICD-9-CM "V" codes are a great help to coders in both inpatient and outpatient settings, but they come with strict parameters where reimbursement is concerned. In most cases, V-codes should not be used as the primary diagnosis. This causes unique challenges for radiology because:
1. Sometimes they are the only appropriate code for a radiological exam.
2. Reimbursement guidelines for V codes can vary from payer-to-payer and sometimes within a state, making it difficult and time-consuming for coders to keep up.
When a V Code is the Only Option
|Tips for V Codes in Radiology|
Visit fiscal intermediary Web sites often to learn regional reimbursement rules and keep up with changes.
Read local coverage determinations (LCDs) to understand medical necessity edits by procedure.
Learn list of approved V codes for your location.
Remember to think creatively when using V codes.
A common reason to use a V code in radiology is when there is no clear reason (or indication) for the exam. This is often the case when findings are normal and the referring physician provides no up-front documentation. Reimbursement for the V code--or lack thereof--doesn't matter. It is your only choice!
In these cases, coders are helpless on a case-by-case basis. Instead, the focus should be on tracking and reporting of the big picture. We suggest radiology departments monitor these cases and provide high-level reports to their medical staff and financial executives. Potential reimbursement shortfalls and denial rates should be included in these reports. Finally, the use of V codes due to no other clinical justification for the exam could be used as a key performance indicator (KPI) for both radiology and HIM departments. Department heads can query on certain V codes and track their use by percentage from month-to-month.
When a V Code is the Right Choice, but Not a Sure Bet
Another common use of V codes is for follow-up exams such as post-cancer metastasis evaluations and post-fracture exams to measure healing. In these cases, the use of V codes is appropriate, but may not always be reimbursed. In Wisconsin and Minnesota there are guidelines for when V codes are appropriate. One example is a follow-up chest X-ray, which is often reimbursable, but the V codes for "history of fall" and "observation following an injury" are not. In this case, coding the actual symptoms first may be the best option. With the use of V codes in radiology, there is a thin, gray line and it is often difficult to see!
That leads us to our next major challenge for radiology coding--varying reimbursement rules!
Gerri Says "Yuns" and Jeff Says "Y'all"
Gerri is from Pittsburgh and Jeff is from Atlanta. Just as accents and idioms vary by region, so do reimbursement rules for radiology coding. What may be paid in one region of the country may not in another. For example, Pennsylvania does not cover chest X-rays for ventilator dependence alone (V46.11), but Wisconsin does. A similar situation occurs with code V71.1, observation for cancer.
You are never positive that a V code will be reimbursed without checking the Web site of your fiscal intermediary. Knowing what is covered based on payer and region takes time and experience. But it is the only way to ensure accurate reimbursement when V codes are used.
There are times when an alternative V code can be used--one that is reimbursable. For example, in a recent case the V code for ultrasound follow-up, post-transplant was not covered, but the V code for status-post transplant was. Coders may need to think outside the box to find the right, reimbursable, V code.
Finally, some out-of-the-box thinking may be required to successfully use V codes in radiology. Don't be limited by your training or old rules. V codes and reimbursement--they are always changing!
Gerri Walk and Jeff Pilato are both with Health Record Services Corp.