Coding Strategy

Align ‘medical necessity’ with ICD-9 instruction.

Ordering a human papillomavirus (HPV) screen with a Pap test isn’t the same as ordering a reflex HPV screen following an abnormal Pap. Although ICD-9 instruction and coverage rules might appear to be at loggerheads, our experts can show you the way out.

Question: Should the physician order a screening and/or reflex HPV Pap test (such as 87621, Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe technique) with V73.81 (Special screening examination for human papillomavirus [HPV])?

What you stand to gain: “Many ‘V’ codes are paid as part of a screening benefit for patients who have those specific benefits,” says Tina Burkhalter, billing manager with SouthEastern Pathology in Rome, Ga. On the other hand,

“tests ordered with diagnostic codes tend to go to the deductible,” she says. “We hear from patients complaining that they must pay for the HPV test because their insurer tells them we used the ‘wrong’ code.”

Medical Necessity Points to 795.0x

Although no national coverage policy exists for screening HPV testing to evaluate cervical cancer risk, many payers follow the consensus guidelines recommended by the American Society for Colposcopy and Cervical Pathology (ASCCP).

A core ASCCP recommendation is to screen for high-risk HPV DNA in patients over the age of 20 years with a Pap cytologic result of 795.01 (Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASC-US]). The guidelines also address the role of HPV with other Pap outcomes in special populations, such as recommending reflex HPV testing for postmenopausal women with cytologic findings of 795.03 (Papanicolaou smear of cervix with low grade squamous intraepithelial lesion [LGSIL]).

Key: If your payers have adopted any or all of these guidelines, you’ll need to report the Pap findings, such as 795.01, to show medical necessity when the lab “reflexes” the specimen to a high-risk HPV screen, such as 87621, following abnormal Pap.

For instance: National Government Services has a local coverage determination (LCD) that points you to 795.00, 795.01, or 795.02, when appropriate, to show medical necessity for 87621 (available online at www.cms.gov/mcd/viewlcd.asp?lcd_id=29508&lcd_version=9&show=all).

“Historically, the recommendation for labs has been to use the abnormal Pap findings (795.xx) as the ordering diagnosis for a reflex HPV screening test,” says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

ICD-9 Directs You to V73.81

The screening gynecological exam code (V72.31, Routine gynecological examination) used to serve for HPV test orders — but no more. ICD-9 added a text note: “Use additional code to identify: human papillomavirus (HPV) screening (V73.81). Similarly, a note following screening Pap test code V76.2 (Routine cervical Papanicolaou smear) states “excludes special screening for human papillomavirus (V73.81).”

Those instructions indicate that you should use V73.81 to order a screening HPV test in addition to a Pap test if the ordering physician wants the HPV test run regardless of the Pap test result.

Learn more about sorting out the instructions and get sample scenarios by subscribing to Pathology/Lab Coding Alert (Editor: Ellen Garver, CPC).

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You’ll turn to a V code when your neurologist reports ‘no effects,’ however.

When your neurologist sees a patient who had a stroke, either recently or in the distant past, he may record a number of different conditions — which makes your job more difficult. If you remember a few guidelines, you’ll select the proper ICD-9 codes for every cerebrovascular accident (CVA) case your neurologist treats.

Get Specific With 2 CVA Diagnosis Codes

When your neurologist sees a patient who has had a stroke, or CVA, he may document multiple deficiencies, both new and lingering. When the patient presents with speech and language deficits you have two diagnosis codes to choose from.

To help both differentiate the etiology of speech and language deficits, and to add specificity to those deficits, ICD-9 2010 includes two cerebrovascular disease lateeffects codes: 438.13 (Late effects of cerebrovascular disease, speech and language deficits, dysarthria) and 438.14 (…, fluency disorder [stuttering]).

If you are not aware of the “combined” ICD-9 late effects codes often you might misreport the ICD-9 code(s) indicating that the patient has the active or ongoing condition, in this case a CVA, rather than reporting the compliant late effect code.

Example: Your neurologist sees a patient who suffered a stroke three years ago and has subsequent hemiplegia on her right (dominant) side. In this case, you may report 434.91 (Cerebral artery occlusion, unspecified, with cerebral infarction) and 342.91 (Hemiplegia, unspecified, affecting dominant side) in error as if the patient is actively being treated for a current occlusion and hemiplegia rather than reporting the correct combined late effects code, 438.21 (Late effect of cerebrovascular disease; Hemiplegia affecting dominant side), says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver.

Change Your Late Effects Code Thinking for CVA

Coding for CVA patients is done somewhat differently than coding late effects from other conditions, such as a spinal cord injury from an accident.

Key: When reporting late effects of a stroke, you only need to use a single ICD-9 code to describe the late effects or manifestations of the CVA, rather than report two ICD-9 codes — one for the residual effect and one for the condition’s cause or as sometimes referenced as the etiology of the manifestation.

Codes describing late effects of stroke appear in a separate section of the ICD-9 manual (438). These codes, such as 438.11 (Late effects of cerebrovascular disease; aphasia) and 438.21 (… hemiplegia affecting dominant side), describe both the manifestation and the etiology of the condition.

Let Documentation Guide You on Active vs .Late Effects

“A late effect is any residual effect that ensues from the original injury and/or condition and can be coded as such at any time after the onset of the condition,” says Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas.

Example: A patient may have a vertebral fracture and continue to have pain years after the fracture heals. Some late effects present early, while others might only become apparent months or years later.

Warning: Don’t confuse late effects with complications. A complication is typically associated with a difficulty or problem that occurs with a specific procedure (996.xx) and not a condition due to the original disease or injury.

To determine if a condition is a late effect, you should look in your neurologist’s documentation for keywords such as:

• due to — such as “pain in right hip due to fracture last year”
• following — such as “personality changes following a brain injury in 1996”
• as a result of — such as “hemiplegia as a result of CVA”
• residual effect — such as “arthritis that is a residual effect of previous hip fracture.”

Capture ‘No Effects’ With V12.54

There can be instances where a patient who suffered a CVA does not have any neurologic deficits present. Find out what to do in those cases by subscribing to the Neurology Coding Alert. Editor: Joshua Thines.

Sign up for the upcoming on-demand Webinar, 5 Steps to Optimize Your Office’s Coding & Billing Practices, or order the CD/transcripts.

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Don’t be caught asleep: Patient history is one element of proper Dx coding.

Many coders hesitate to report V codes, or simply use them incorrectly, but sometimes this section of ICD-9 most accurately describes the reason for the patient’s condition. In fact, V codes are often essential to reporting an anesthesia patient’s medical history.

If you’re not clear on the importance of V codes, check out these expert-approved answers to some often-asked questions:

Why Should I Use V Codes?

To determine if you should use a V code, look for documentation in your anesthesiologist’s report that will support physical status modifiers or use of Monitored Anesthesia Care (MAC), says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Knowing that a patient has a history of certain problems (such as a history of sudden cardiac arrest) could affect how your provider delivers anesthesia or monitors the patient. The personal history might also help justify having anesthesia services available (either already providing service or with the anesthesiologist on stand-by) for procedures that might not normally need anesthesia.

Important: V codes are not only appropriate as secondary codes. You may occasionally encounter a situation where a V code is necessary as the primary diagnosis. In some cases, reporting a V code might be the only way you’ll be paid for a service.

“If there are chronic conditions that affect the physical status, such as diabetes, lung disease, or cardiovascular disease, then these should be coded in addition” to the current diagnosis codes, says Julee Shiley, CPC, CCS-P, ACS-AN, a coding professional in North Carolina.

Example: A gastroenterologist requests your anesthesiologist at a colonoscopy because the patient has been resistant to moderate sedation in the past. Using V15.80 (History of failed moderate sedation) could justify why the anesthesiologist was at the colonoscopy.

Look for Symbols Indicating V Code Use

“Coders that are not aware of the ICD-9 history codes often err and report the ICD-9 code(s) indicating that the patient has the active or ongoing condition, rather than reporting the compliant and associated patient history code,” Dennis says.

If you find it tricky to distinguish primary from secondary V codes, ICD-9 gives you some helpful hints. Many versions of the ICD-9 manual use a symbol, such as a “1” or a “2” inside a circle, to indicate in what order you should report the code (such as “first listed or primary Dx,” “first listed or additional,” or “additional or secondary Dx only”). You’ll find these indicators next to the code descriptor.

Example: An anesthesiologist provides MAC to a patient with a history of transient ischemic attack (TIA), an episode in which a person has stroke-like symptoms for less than 24 hours. According to ICD-9, you may report V12.54 (Stroke [cerebrovascular]) as the primary diagnosis and the reason for the surgery as the secondary diagnosis.

How Do I Use V Codes For Anesthesia?

Use of V codes for anesthesia can be very different from other specialties’ use of the codes. Find out how by subscribing to the Anesthesia & Pain Management Coding Alert.

Editor: Joshua Thines

Sign up for the upcoming live audio conference, Anesthesia Coding 101, or order the CD/transcripts.

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Get ready for the dawn of new jaw pain, BMI codes, among others.

If you’ve got high hopes that you’ll benefit from many new ICD-9 codes starting this fall, CMS delivers, with over 130 new diagnosis codes debuting on Oct. 1. CMS published the full listing of codes in a 1,000+ page Federal Register file, but we’ve reviewed the list, and it offers a few surprises.

Over one-third of the new codes can be found in the “V” code section, which describe “supplementary classification of factors influencing health status and contact with health services,” according to the ICD-9 manual.

BMI Info Is Now Clearer

“They’ve expanded the body mass index (BMI) codes to demonstrate higher BMIs with five new codes,” notes Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC with CRN Health-care Solutions in Tinton Falls, NJ.

Whereas in the past, you had just one V code to represent a BMI index over 40 (V85.4), the new edition of ICD-9 will offer additional categories, ranging from a BMI of 40.0 to 44.9 (V85.41) through a BMI of 70 and over (V85.45).

“BMI has become an important health tool, and those codes will also provide more data,” says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting & Coding Education, LLC. “There are seven vital signs that count for the constitutional bullet in the E/M review of systems coding, and there are those who are of the opinion that BMI should be an eighth option, especially in bariatrics and orthopedics/sports medicine.”

If that eighth bullet does gain traction and come into play for coders, the new V codes could help considerably.

New Jaw Pain Code Debuts

Pain code: You’ll find new code 784.92 (Jaw pain) effective Oct. 1. According to notes made by the ICD-9-CM Coordination and Maintenance Committee in Sept. 17, 2009, “it was suggested to somehow differentiate temporomandibular joint disorders and this code, perhaps using an excludes note.”

Want to know more about ICD-9 codes that you’ll be able to use this October? Subscribe to Part B Insider. Editor: Torrey Kim, CPC

Sign up for the upcoming on-demand Webinar, 5 Steps to Optimize Your Office’s Coding & Billing Practices, or order the CD/transcripts.

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Question: Our hospital billing and medical departments say that diagnoses we add to a claim for reimbursement must have a physician endorsement. We’ve researched our Local Coverage Determination (L26884) from National Government Services, the Ingenix Coding & Payment Guide for the Physical Therapist, and our Indiana Practice Act but can’t find a conclusive reference stating a physical therapist can make a treating diagnosis without an MD’s endorsement. Our billing dept suggested we send all POCs to the MDs for co-signature. But we’d rather not increase the paper flow to the MDs.

Can you offer a reference that states PTs can make treating diagnoses that can stand alone without the MD endorsement?

Indiana subscriber

Answer: Posing the question back to you, have you found a reference that states PTs can’t make treating diagnoses that can stand alone for claims submissions, medical records, etc. without the MD? More likely, you won’t find a reference stating guidance either way. Your best resource is your state chapter organization as well as the American Physical Therapy Association.

Page 14 of the following link from the Centers for Medicare & Medicaid Services (CMS) offers more details: www.cms.hhs.gov/manuals/downloads/clm104c05.pdf. It says, “Bill the most relevant diagnosis. As always, when billing for therapy services, the ICD-9 code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason.”

The manual then offers an example of a patient with diabetes being treated for gait training due to amputation. “The preferred diagnosis is abnormality of gait (which characterizes the treatment),” CMS says. “Where it is possible in accordance with state and local laws and the contractors local coverage determinations, avoid using vague or general diagnoses.”

@ Physical Medicine & Rehab Coding Alert, Editor: Lindsey Rushmore

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Want to know more about physical medicine & rehab coding? Check out this upcoming audioconference or order a transcript/CD: Decrease Inappropriate PT and OT Referrals in Acute Care.