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Posted By Amanda on 03-19-2002, 15:16:00 in Ophthalmology
We have a patient that came to us after the global period of a muscle
surgery for a 4 month check up.

What type of diagnosis code would we use?

Thanks!!

Amanda
Comments (7)
Posted By S on 04-01-2002, 12:52:00
Dr Anderson:

>There are other codes to use when there is a surgical complication - -
>starting about 996 in the ICD-9. So the V codes would be when there is no
>complication, especially one with symptoms that caused a service to be
>scheduled.

Yes for the most part. But there are those that pertain to a problem with a
specific area...but I won't get into that at this time.

>What do you think the "only" means? That you only did surveillance and had
>no symptoms or other reason to see the patient? Or that this code applies
>only after the surgery is complete, that is, after the global period? I am
>assuming the both, based on analogy with V67.2 and V67.51. After treatment
>(radiation, surgery, medication, whatever) seems to be completed, and the
>disease is gone (appendicitis, cancer, cataract) there is a continuing
>medical need for regular monitoring of an asymptomatic patient. But you
>have to be realistic. There is not need to follow up on an appendectomy
>indefinitely, but there may be for treatments of a malignancy, which might
>recur at a treatable stage without signs or symptoms, or an implant might
>cause a problem that is better treated while the patient is still
>asymptomatic.

Again, yes for the most part. If you have symptoms, then you'd use those
symptom codes, and if there was a complication from the procedure, a 900
level code. But there are also codes for surgery follow up so I wouldn't get
them mixed up with the follow up you are doing for the disease, ie chemo or
whatever high risk meds one is using (V67.2 and V67.51). BTW, I found a
typo!!! at V67.5 section in my book - I a definitely need a vacation!

>V codes are a funny thing, aren't they... All you can do is be
>honest in identifying why you provided the service, whether that reason be
>in the "V" section or somewhere else. That's the coding issue, and who
pays
>for it is another issue.

I wholeheartedly agree.

Stacey Levitt


Posted By douglas on 03-30-2002, 13:02:00
I think SURGICAL aphakia may be a V code, V45.61, and pseudophakia is V43.1.
My ICD-9 book under aphakia (379.31) says it excludes cataract extraction
status V45.61. When you look under V45.6X, you find 379.31 is excluded.
Hence these two codes are in each place listed as mutually exclusive. Now
exactly what non-surgical aphakia is I have never figured out, so I do quite
get this one.

It would be good to know that if the doctor thinks the patient should come
back four a routine one-year follow-up after some surgery, that would
satisfy the medical necessity requirement. Fortunately for me, it works for
glaucoma - - the patient really does still have glaucoma after filtering
operation.

But what about a strabismus operation that achieves alignment (the question
that started this exchange)? Does the child still have strabismus, or is
the strabismus gone and you are screening him to see whether there is a
recurrence. In principle it is not much different from seeing whether the
IOP became elevated again after a filtering operation, but glaucoma is
defined as much by the presence of field loss and disc cupping as by IOP, so
the person still has glaucoma after the IOP is in the statistical normal
range. So we have a diagnosis to use. But, the question is, what to use
for status post successful alignment by muscle surgery. When alignment is
achieved, the strabismus is gone (like appendicitis). Therefore, V67.0 is
the closest I have ever been able to find.

ICD-10 promises to fix a lot of this stuff.

Douglas R. Anderson

Posted By michael on 03-30-2002, 04:23:00

In a message dated 3/28/02 12:47:44 PM, danderson@med.miami.edu writes:

<< Does anyone

know how one correctly distinguishes post-op patients that need long term

monitoring from those who really don't need follow-up until they develop

symptoms (like, I don't need to see my surgeon again more than 90 days after

appendectomy unless I develop abdominal symptoms). I have wondered if V67.0

does the job. Rather than V45.69. >>

I believe that I heard in some course that if the doctor recommends a
followup visit to monitor an underlying condition, (as opposed to the patient
coming in on their own), then that meets the criteria of medical necessity.
If this is the case, as long as you feel that it is medically justified to
examine the patient, and it isn't routine, you should be covered. In some
cases, such as glaucoma or ARMD, there is a clear condition to code. In other
cases, postsurgical, it may be hard to find a non V-code. I think that this
is because part of the medical justification is to pick up late complications
even if they aren't yet symptomatic; yet this borders on screening exams. But
why is pseudophakia a V-code, while aphakia is not? I think what we need is
for our academy to push for some better diagnosis codes for these situations.

Dr. Yaros
Posted By douglas on 03-29-2002, 21:19:00
Stacey,

Yes, I was looking at V67.0_ almost like a medically justifiable screening
or "surveillance". No symptoms or problems that the patient recognizes (at
least at the moment), but at a certain interval after "completed treatment"
(be it radiation, surgery or chemotherapy) you see the patient as a matter
of routine, in order to see whether there are any asymptomatic complications
or (in the case of cancer) recurrences. And perhaps in the case of IOL
prosthesis, whether there are asymptomatic complications arising from the
IOL. Although, as John Bell points out, the psuedophakia V code does the
same thing. However, I was taught that pseudophakia would not be paid - - I
should check out whether our claims with pseudophakia as a diagnosis were
paid despite what I was taught.

There are other codes to use when there is a surgical complication - -
starting about 996 in the ICD-9. So the V codes would be when there is no
complication, especially one with symptoms that caused a service to be
scheduled.

What do you think the "only" means? That you only did surveillance and had
no symptoms or other reason to see the patient? Or that this code applies
only after the surgery is complete, that is, after the global period? I am
assuming the both, based on analogy with V67.2 and V67.51. After treatment
(radiation, surgery, medication, whatever) seems to be completed, and the
disease is gone (appendicitis, cancer, cataract) there is a continuing
medical need for regular monitoring of an asymptomatic patient. But you
have to be realistic. There is not need to follow up on an appendectomy
indefinitely, but there may be for treatments of a malignancy, which might
recur at a treatable stage without signs or symptoms, or an implant might
cause a problem that is better treated while the patient is still
asymptomatic.

V codes are a funny thing, aren't they. They are reasons for a medical
service (needs drivers license, certification of disability, family history
of something, or personal history of having had something, or maybe
post-operative states). They don't represent diseases or symptoms or signs
or medical conditions that seem to mandate medical care, but in some cases
they are medically reasonable or wise. A family history of colon cancer is
a valid reason for colonoscopy, and as such is recognized by some carriers
to be within the medical coverage they provide. Some medically wise things
to do (preventive medicine in general, let's say) may be within the scope of
a medical insurance or other contractual coverage, and others may not. Some
V codes are paid by some carriers, but others are not. All you can do is be
honest in identifying why you provided the service, whether that reason be
in the "V" section or somewhere else. That's the coding issue, and who pays
for it is another issue.

Doug Anderson
Posted By S on 03-28-2002, 17:23:00
Dr Anderson:

V5.6_ refers to the person with a condition (some type of state following
surgery of eye and adnexa)that affects their health status. Although it may
occur again and again, for this visit, it is affecting them. Per the book,
"...these categories are intended for use when these conditions are recorded
as "diagnoses" or "problems"..." V67.0_ would include "surveillance ONLY
following completed surgery" (my boldface type). It is not usually used for
"problems" post-op. I look at it as almost a screening code, because when
I've used it in GYN, it has been for followup after some type of surgery
for a GYN cancer where the physician does a vaginal pap to check for
recurrence of malignancy (you can't use the cervical pap codes here). Just
my opinion; hope it helps...

Stacey Levitt,RN,MSN,CPC
Posted By douglas on 03-28-2002, 16:51:00
This brings up a general problem that goes beyond the case presented.

So, I have appendicitis, appendix is removed. Post-op for 3 months, but if
9 months later I see the doctor, there has to be a reason other than
appendicitis, because I don't have appendicitis any more. Post-op
appendectomy is also not a medically necessary reason for an E/M service of
any kind.

Similarly, had cataract, had cataract removed with IOL implant. After the
post-op of 90 days, can't exactly use pseudophakia ( A "V" code) and expect
it to be a payable (medically necessary) diagnosis. Irritation that turns
out to be corneal edema from mechanical complication of the IOL - - well,
that becomes a payable, medically necessary visit.

Now turn to glaucoma. Have glaucoma, had trabeculectomy, IOP is now normal.
But needs long term follow-up anyway, and continues to carry the diagnosis
of glaucoma. In other words, I lowered the IOP, but didn't get rid of the
glaucoma.

Strabismus really resembles the glaucoma situation. The surgery may have
corrected the misalignment, but it can always recur, so needs regular
monitoring, so that if esotropia recurs, something can be done to restore
alignment or at least prevent amblyopia. It would be asymptomatic, and
suppose that in fact on the 4-month exam the eyes have remained straight as
you would hope. Can't exactly use esotropia for a diagnosis, but it may
indeed be true that this exam was medically reasonable. And post-op
diagnosis without symptom may not be paid.

Similar problem with keratoplasty, which some cornea surgeons feel needs
regular monitoring to detect early rejection before it becomes symptomatic,
but I don't know. Also retina surgeons feel that after RD is repaired,
patient should be seen regularly. I don't know whether these instances
resemble more the appendix and cataract examples or the glaucoma and
strabismus examples. But in any case, it is a coding problem. Does anyone
know how one correctly distinguishes post-op patients that need long term
monitoring from those who really don't need follow-up until they develop
symptoms (like, I don't need to see my surgeon again more than 90 days after
appendectomy unless I develop abdominal symptoms). I have wondered if V67.0
does the job. Rather than V45.69.

Douglas R. Anderson
Posted By Amanda on 03-25-2002, 23:25:00
Has anyone had the belowe situtation and what did they do for the dx code.

Amanda
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