DRG Coding Advisor: Be sure to follow coding guidelines when using V-codes
DRG Coding Advisor: Be sure to follow coding guidelines when using V-codes
Payers could be ignoring V-code rules
Payers and providers sometimes do not follow coding guidelines, or they may create their own rules that conflict with official coding guidelines, creating problems for the coders caught in the middle.
"You have payers that are forming their own rules, which sometimes conflict with the official coding guidelines," says Joann Becker, RHIT, CCS, a health information management consultant in Fairfax, IA. "And you have some providers, on the other hand, wanting to get their encounters paid for, and they’re stuck in between by coding per guidelines."
This problem also surfaces in data collection and may result in warped data being used to form medical policies, Becker adds. One example of this problem is when payers won’t accept a V-code in a place where a V-code is absolutely appropriate to use, Becker says.
V-codes have a wide variety of uses
V-codes, which are used to describe generally healthy patients who seek health care, may be used to describe someone who has come in for a general medical exam but who has no presenting signs or symptoms. These codes also can be used to describe a significant health condition, such as a patient with a pacemaker or colostomy who needs follow-up care. Also, V-codes can be used for patients who visit outpatient settings to have sutures removed, Becker explains.
"Some payers incorrectly assume that the patient does not have a condition that warrants a health care encounter when a V-code is used," Becker says. "But a V-code is the appropriate code to use when a patient has cancer and the purpose of the visit is for chemotherapy or radiation therapy."
A code from category V-58 would be sequenced first, followed by the code for cancer, Becker explains.
The payers may have a computer system that automatically rejects the V-code, so while it would seem to be an easy problem to fix, it is not.
Coders should be aware of how the claim actually leaves the facility, Becker says. "In some cases, codes are switched around by billing software or by billing staff themselves," she explains. "Billing staff and coders need to communicate with each other to better understand coding guidelines and billing requirements."
Some V-codes appropriate for outpatients
They should keep in mind that V-codes may be used to describe outpatient encounters as well.
"In the outpatient arena, some V-codes are appropriate for use according to official coding guidelines," Becker says. "We would use a V-code to describe a patient’s encounter, but some payers won’t accept them."
Various organizations, including the American Health Information Management Association (AHIMA) of Chicago, have been working on trying to get all health care organizations and payers to follow coding guidelines, but it will take continuing education, Becker says.
"We’re only going to get accurate coding when we all follow the same rules," Becker notes. "While a payer only has their own set of guidelines to follow, providers have many different payers and policies to follow, and it gets more and more complicated."
Thanks to new requirements under the Health Insurance Portability and Accountability Act (HIPAA), it appears that consistent coding guidelines will be required of all payers and providers. However, HIPAA regulations still are being modified and may not be finalized until next fall.
Until there is consistency across the health care and payment continuum, here are some strategies for dealing with V-code problems, Becker suggests:
• "Probably the best solution is to work with each payer, sending copies of the guidelines, writing official letters, keeping documentation for follow-up, and maintaining documentation of communications with payers," Becker says.
Even if it takes one-to-one education, coding departments should do their best to get the message across that there are industry-accepted guidelines for the various coding definitions.
"If a payer says, We won’t pay it that way,’ then the coder is kind of stuck, and should keep that documentation for support if that claim ever comes back," Becker says.
• Coding problems often occur with the V-10 category for history of malignant neoplasms. For example, a patient with breast cancer is seen in a physician follow-up, although the patient no longer has breast cancer because it has been treated and therapy is complete, Becker says.
"But many payers may not accept a V-10 category code, so they’re requiring the physician to code it as a current breast cancer, and that’s not right because the patient doesn’t have breast cancer anymore," Becker says. "That’s a problem of being stuck between the correct coding and coding for payment and reimbursement."
The way Becker handles a V-10 denial is to call the payer representative to explain how the V-10 code was used and to find out what the real reason behind the denial was.
If the denial was the result of a coding problem, then Becker will try to work with the representative as best she can. Often, she’ll send the person a follow-up letter with some copies of specific coding guidelines for evidence of how the V-10 code should be used.
"Again, it’s a David and Goliath situation, one person trying to change the whole institution’s thinking," Becker says.
"So the best thing you can do is to track documentation and keep working on that," she says. "Sometimes you will get paid, and some payers absolutely will refuse to accept those V-codes, and so there is no real easy answer to the problem."
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