Health Information Management

Tip: Know the guidelines for reporting ICD-9-CM V codes

APCs Insider, June 29, 2012

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According to the ICD-9-CM Official Guidelines for ­Coding and Reporting, coders should report V codes in four primary circumstances, one of which relates to aftercare as follows:

A person with a resolving disease or injury, or a chronic, long-term condition requiring continuous care, encounters the health care system for specific aftercare of that disease or injury (e.g., dialysis for renal disease; chemotherapy for malignancy; cast change). A diagnosis/symptom code should be used whenever a current, acute, diagnosis is being treated or a sign or symptom is being studied.
 
These official coding guidelines also provide the following guidance regarding the appropriate use of aftercare codes:
 
 
 
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. The aftercare V code should not be used if treatment is directed at a current, acute disease or injury. The diagnosis code is to be used in these cases.
 
Now let’s consider a patient with a traumatic finger amputation who presents with an amputation stump and concern for infection at the amputation site.
 
There are no obvious signs and symptoms of infection at the amputation site, and the patient is receiving antibiotics presumably as a prophylactic measure for infection. In this case, the aftercare code V54.89 is the most appropriate ICD-9-CM code to report for this encounter.
 
The patient’s status is post initial treatment of the traumatic amputation, and he or she is currently in the healing or recovery phase. The physician isn’t directing the current treatment toward a current injury. Thus, it’s inappropriate to assign a code from the 800 series to indicate a current injury for this encounter. Likewise, it’s inappropriate to assign the V54.89 code along with an acute injury code, given the fact that aftercare codes shouldn’t be assigned when treatment is directed at the current injury. Therefore, report only code V54.89.
 
By definition, codes from the 800 set and V54.89 shouldn’t be reported together.
 
The tip is adapted from “This month’s coding Q&A” in the June Briefings on APCs.



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