Using V codes to indicate medical necessity

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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I saw a patient for melanoma follow-up. There were no suspicious lesions present on exam. Do I use a diagnosis of melanoma for the visit?

No. The diagnosis of melanoma is only used until definitive treatment has been performed (the wide excision). For subsequent visits, it is replaced by the history of melanoma code V10.82.

Medicare does not pay for most preventive medicine services, such as routine cancer screening. Thus, a screening skin exam without a presenting complaint would not be a covered service by Medicare. Patients must have a diagnosis and chief complaint in order for a service to be billable. For a skin cancer follow-up visit, V codes indicate why the visit was medically necessary. Medicare carriers generally accept V10.82 (personal history of melanoma) and V10.83 (personal history of other malignant neoplasm of skin) as primary diagnoses codes.

ICD-9-CM Official Guidelines state, “...family history codes may be used in conjunction with screening codes to explain the need for a test or procedure.” The guidelines also state, “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.” This becomes important when ordering tests for symptoms such as generalized pruritus. Many carriers have local coverage determinations which are medical review policies that cover medically necessary testing prompted by symptoms, and physicians should be familiar with the local policies.[pagebreak]

Other V codes can also be useful to explain why a service was medically necessary.

V58.41, Aftercare

ICD-9-CM Official Guidelines state, “Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.” Note that the aftercare V code would not be appropriate if the visit was prompted by a new complaint or treatment as this code is directed at a current, acute disease or injury. In such case, the most specific diagnosis code should be used.

V58.0, Encounter or admission for radiotherapy

V58.1, Encounter for chemotherapy and immunotherapy for neoplastic conditions

These codes are to be listed along with the specific diagnosis code when a patient’s encounter is solely for the purpose of receiving radiation therapy or chemotherapy for the treatment of a neoplasm. If it is medically appropriate for a patient to receive both chemotherapy and radiation therapy during the same encounter, codes V58.0 and V58.1 may be used together, with either one being sequenced first.

V58.83, Encounter for therapeutic drug monitoring

This code should be used for an encounter to monitor potential adverse affects of medication. It indicates that the patient who is on a drug for any length of time needs to be monitored for the level of effectiveness of the drug through a test.

V58.69, Long-term (current) therapy with a high-risk medication

Reporting this code indicates that the patient is or has been on a high-risk drug for a long-term period.

For any associated long-term high-risk drug use, V58.69 and/or V58.83 should be added, as they explain the medical necessity of a visit or ordering tests to evaluate for the level or effectiveness of the drug while a patient is on a medication. These codes’ concepts are mutually exclusive and they can be used together.

Example: When placing lab orders for a patient on isotretinoin, V58.83 should be associated with the orders, with acne (706.1) being the secondary diagnosis, as the reason for the blood test is the isotretinoin therapy, not the acne. If this same patient on isotretinoin is seen for an office visit, V58.69 would be an appropriate primary diagnosis with acne (706.1) as the secondary diagnosis. Always consult your payers’ medical policies, as V codes are not universally accepted as primary diagnoses.

Want to learn more? The ICD-9-CM Official Guidelines are available at www.cdc.gov/nchs/data/icd9/icdguide09.pdf.