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The use of "diagnostic V codes" in pediatric ophthalmology
1Department of Ophthalmology, Children's National Medical Center and George Washington University, Washington, DC 20010-2970, USA.
Insights
Diagnostic V codes, specifically V71.8, were accepted by insurers for medically necessary pediatric eye screening examinations when patients were normal. This finding supports their appropriate use in such clinical scenarios.
Area of Science:
- Ophthalmology
- Medical Coding
- Healthcare Reimbursement
Background:
- Pediatric ophthalmologists perform comprehensive eye exams for hereditary diseases or systemic conditions.
- Medically necessary screening exams for 'normal' children are often unreimbursed by insurers.
- This study investigated the use of diagnostic V codes for such screenings.
Purpose of the Study:
- To evaluate the acceptance rate of diagnostic V codes by insurers for normal pediatric eye screening examinations.
- To determine if V codes are appropriate for medically necessary screenings that yield normal results.
Main Methods:
- A list of 11 primary and 7 secondary diagnostic V codes was implemented in a pediatric ophthalmology practice.
- Insurer acceptance of these V codes was tracked over an 8-month period.
- Data analysis was performed one year later on closed accounts.
Main Results:
- The V code V71.8 ('observation for other specified, suspected condition') achieved a 73% acceptance rate.
- This acceptance rate was consistent whether V71.8 was used alone (76%) or with a secondary code (71%).
- Other V codes were rarely utilized by the practice.
Conclusions:
- Diagnostic code V71.8 is an accepted code by local insurers for medically necessary screening eye examinations in children found to be normal.
- The high acceptance rate supports the use of V codes as appropriate and correct for these specific clinical situations.
- This practice provides a viable solution to the reimbursement challenge for essential pediatric eye screenings.
Background:
Children requiring comprehensive eye examination for signs of familial eye disease or suspected systemic condition are referred to pediatric ophthalmologists. Such examinations may be critical to diagnosis and patient management, yet medically necessary screening examinations are not reimbursed by insurers when the patient is "normal." Faced with this dilemma regularly in a children's hospital practice, we began tracking insurer acceptance of "diagnostic V codes," which are diagnostic codes generally related to symptoms or status conditions rather than to medical states. The authors felt that "diagnostic V codes" might represent a more appropriate and correct code in the circumstance of a medically necessary screening examination found to be normal.
Methods:
In July 1995 the use of 11 primary diagnostic V codes and 7 secondary diagnostic V codes was discussed in our faculty meeting and a list was displayed in each examination lane. Acceptance of V codes was then tracked for an 8-month period and analyzed 1 year later to provide a set of closed accounts.
Results:
The code V71.8, or "observation for other specified, suspected condition" had a 73% acceptance rate by insurers on the basis of 207 examinations. The acceptance rate was not dependent on the use of a secondary code (76% for V71.8 alone vs 71% for secondary code used). Other V codes were infrequently used.
Conclusions:
The code V71.8 was an accepted code by insurers in our locality for medically necessary screening examinations found to be normal. The authors feel this high acceptance rate by insurers confirms our impression that V codes are the appropriate and correct codes to use for the medically necessary screening examination found to be normal.