The ICD-9-CM coding nomenclature includes a set of codes that begin with the letter "V"--hence the name V codes. V codes are an additional classification of factors influencing the patient's health status and contact with health care services. They cover a range of health scenarios including, for example, a pregnancy, a history of cancer or a history of transplant (in most cases, V-codes shouldn't be used as the primary diagnosis). V codes are a great help to coders in both inpatient and outpatient settings, but they come with strict parameters regarding reimbursement, especially in the radiology arena.

The use of V codes is a challenge--and opportunity--for radiology coders for two key reasons:

• Sometimes they are the only appropriate codes for specific radiological exams.
• 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

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's your only choice!

 On a case-by-case basis, coders are helpless. Instead, the focus should be on tracking and reporting 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 health information management (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" aren't. 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 that is often difficult to see!

That leads us to our next major challenge for radiology coding, varying reimbursement rules.

Gerri says "yuns," 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.

These reimbursement differences plague all of coding and reimbursement where V codes are concerned. You can never be 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's 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. In addition to knowing fiscal intermediary guidelines, coders may need to think outside the box to find the right, reimbursable V code.

Tips for V code success

As mentioned above, the first step is to visit your fiscal intermediary Web site. There, you can read your local coverage determinations (LCDs) to learn which V codes meet medical necessity edits for certain radiologic procedures. LCDs are contractor-developed coverage policies, pertaining to services or items not addressed in national coverage determinations (NCDs) or program manuals. Most carriers and/or contractors create LCDs to:

• define the appropriate use of new technologies.
• address services with an abuse history or potential.
• designate high volume, high dollar services.

We suggest coders become very familiar with the appropriate LCDs for their area. Review the list of approved V codes and learn the rules for their specific regions and locations. If you are a coder and have recently relocated, the rules you have been using have probably changed. Take the time and do your homework!

Secondly, coders can work together with peers and radiologists to fully interpret the LCDs and find alternative codes that are approved. In many cases, a V code that is approved for one anatomical location may be suitable for another. Most V codes approved for chest X-rays may also be used for radiologic exams of the abdomen.

Finally, you may need to do something outside-the-box thinking 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, RHIA, CCS-P, and Jeff Pilato, MHA, RTR, CPC-H are on staff at Health Record Services Corp., Baltimore.