Clear V72.6x hurdle with ICD-9, coverage guidelines.
ICD-9 guidelines and direction from sources such as Medicare's laboratory National Coverage Determinations (NCDs) make it clear -- you need to code the patient diagnosis that prompts a lab-test order.
"You should encourage physicians to continue to order lab tests with condition codes rather than relying on new codes such as V72.63 (Pre-procedural laboratory examination), if you want to avoid denials"
Identify Lab Test Encounters
Now you have five new codes for lab encounters:
• V72.60 -- Laboratory examination, unspecified
• V72.61 -- Antibody response examination
• V72.62 -- Laboratory examination ordered as part of a routine general medical examination
• V72.63 -- Pre-procedural laboratory examination
• V72.69 -- Other laboratory examination.
Because patients routinely receive blood tests prior to certain procedures, and ICD-9 already provided codes for pre-procedural cardiovascular and respiratory evaluations, the ICD-9 Coordination and Management Committee (CMC) approved a request to add these labencounter codes.
Don't miss: Regarding pre-op lab exams, the ICD-9 CMC says, "These visits are generally done in an outpatient setting days before the treatment or procedure is scheduled," The new codes help explain the reason for the encounter -- but they don't necessarily explain the reason for the specific lab tests.
ICD-9 Guidelines Prioritize Diagnoses
Although V72.60-V72.69 add specificity to reporting encounters for lab tests, you shouldn't routinely use one of them as the only code for a lab exam.
Follow guidelines: ICD-9 "Official Guidelines for Coding and Reporting" state that you shouldn't use V72.6x as the primary diagnosis if you have documentation of "a sign or symptoms, or reason for a test."
"This guidance clarifies that you shouldn't start billing all pre-op or routine-physical lab tests with V72.6x," Because the ordering physician, not the laboratory, assigns the ICD-9 code, you'll need to help your physician clients understand how they should and shouldn't use the new codes. V codes describe the reason for the encounter, but physicians should still use specific condition codes to describe the signs, symptoms, or disease that show(s) medical necessity for ordered tests.
Tip: You can use physician education opportunities and requisition-form design to encourage proper ICD-9 use. Informing physicians that they need to continue ordering lab tests with condition codes will help your lab show medical necessity and get paid for ordered tests. Does that mean you can't use V72.6x as a primary diagnosis? No. ICD-9 lists the code with the ½ indicator, which means that you can use the code as a first-listed or additional diagnosis.
Limit primary diagnosis: You should only list V72.6x as the primary diagnosis "in the absence of any signs, symptoms, or associated diagnosis," according to ICD-9 official guidelines.
NCD States V72.6 Doesn't Pay
Medicare's 23 Laboratory NCDs include lists of covered diagnosis for many common lab procedures. None of the NCDs lists V72.6 as a covered diagnosis. "Because Medicare never listed V72.6 as a covered diagnosis for any of the lab NCDs, it is unlikely that you'll see V72.6x added as covered diagnoses," .
Bottom line: "If you perform diagnostic lab tests based solely on one of the new lab exam V codes, Medicare and other payers will likely determine that you haven't demonstrated medical necessity and decline to pay."