Tuesday, April 7, 2009

The V Coding Trap

We believe there are many flaws in the coding arena and want to discuss one in particular we believe is a trap. Don’t fall into it.

Be aware when using the chemotherapy V Codes (V58.11 or V58.12) or you may not get reimbursed properly for what you are really owed.

Cancer patients have lots of problems, and their treatment if often complex. We firmly believe that “there is no such thing as a routine chemotherapy”. Therefore, oncologists/ hematologists need to assess patients when they arrive for their chemotherapy – to be sure they are stable enough to have their treatment that day. Typically, this assessment would constitute a Level IV or Level V visit. We find this to be true with 90% of the patients in the practices we work with across the country.

Unfortunately, by reporting the V code as a primary diagnosis as required by some local coverage determinations, you are essentially saying the only reason for the encounter was to administer chemotherapy, thereby indicating the evaluation and management service was not necessary and should not be paid. In essence, you’re telling them “Don’t’ pay me” when you do this.

So, how do you get paid for your physician assessment and the chemotherapy? We bill cancer diagnosis as the primary code plus the V code as the secondary, and our clients are getting paid. We’ve not had denials doing it this way. If you use the V code as the primary code, you risk not getting reimbursed for your assessment.

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