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Billing with V Codes
      


Use the correct V-code diagnosis to indicate the reason for the visit. The V code must match the CPT code to indicate the procedure that you are performing as it correlates to the V-code diagnosis. V codes correspond to descriptive, generic, preventive, ancillary, or required medical services and should be billed accordingly. This section covers different types of V codes and their uses.
       

Descriptive V Codes

For V codes that provide descriptive information as the reason for the patient visit, you may designate that description as the primary diagnosis. An example of a descriptive V code includes a routine infant or child health visit, which is designated as V20.2.
            

Generic V Codes

For lab, radiology, pre-op, or similar services, do not use a generic V code as a primary diagnosis. Rather, the underlying medical condition should be listed as the primary diagnosis for these ancillary services.
       

Preventive V Codes

For preventive services, a V code that describes a personal or family history of a medical condition is sufficient as a primary diagnosis without the need for additional diagnostic information. Examples are a mammography, a Pap smear, or a fecal occult blood screening.

Figure 8.1 lists clinical preventive care services and the corresponding V codes.

Note: Codes are subject to change. Please apply the most current coding guidelines.

Figure 8.1 Clinical Preventive Care Services V Codes

Preventive Care Service

Proper V Codes

Care Intervals and Notes

Colonoscopy V70.0
V70.5
V70.9

Individuals at average risk for colon cancer:
Colonoscopy covered once every 10 years beginning at age 50.

Individuals at increased risk for colon cancer:

  • Colonoscopy once every five years for individuals with a first-degree relative diagnosed with a colorectal cancer or an adenomatous polyp before age 60, or in two or more first-degree relatives at any age. Optical colonoscopy should be performed beginning at either 40 or 10 years younger than the earliest affected relative, whichever is earlier.
  • Colonoscopy once every 10 years, beginning at age 40, for individuals with a first-degree relative diagnosed with colorectal cancer or an adenomatous polyp at age 60 or older, or colorectal cancer diagnosed in two second-degree relatives.

Individuals at high risk for colon cancer:

  • Colonoscopy once every one to two years for individuals with a genetic or clinical diagnosis of hereditary non-polyposis colorectal cancer (HNPCC) or individuals at increased risk for HNPCC. Optical colonoscopy should be performed beginning at age 20 to 25 or 10 years younger than the earliest age of diagnosis, whichever is earlier.
  • For individuals diagnosed with inflammatory bowel disease, chronic ulcerative colitis, or Crohn’s disease, cancer risk begins to be significant eight years after the onset of pancolitis or 10 to 12 years after the onset of left-sided colitis. For individuals meeting these risk parameters, optical colonoscopy should be performed every one to two years with biopsies for dysplasia.

There are no copayments or cost-shares required for TRICARE Prime or TRICARE Standard and TRICARE Extra beneficiaries.

Note: Computed tomographic colonography (CTC) is covered as a colorectal cancer screening only when an optical colonoscopy is medically contraindicated or cannot be completed due to a known colonic lesion or structural abnormality, or when other technical difficulty is encountered that prevents adequate visualization of the entire colon. CTC is not covered as a colorectal cancer screening for any other indication or reason.

Mammograms V70.0
V70.5
V70.9		 Performed annually for women beginning at age 40 (baseline at age 35 for high risk, then annually). There are no copayments or cost-shares for TRICARE Prime or TRICARE Standard and TRICARE Extra beneficiaries.

Note: The mammogram and add-on codes must be submitted on the same claim if performed on the same date of service.
Optometry V72.0 Active Duty Service Members (ADSMs)
  • TRICARE Prime ADSMs must receive all vision care at military treatment facilities (MTFs) unless specifically referred to a network provider (or non-network provider if a network provider is not available).
  • TRICARE Prime Remote ADSMs may obtain comprehensive eye examinations from network providers as needed to maintain fitness-for-duty status without an authorization.
Active Duty Family Members (ADFMs)
  • One routine eye examination to check for vision and diseases per calendar year, regardless of TRICARE program option.
  • Medically necessary care for injuries to the eye is covered.
Retired service members and their families (includes all beneficiaries other than ADSMs and ADFMs)
  • If enrolled in TRICARE Prime, one routine eye examination to check for vision and diseases every two years is covered (except for diabetic patients, see later in figure).
  • If using TRICARE Standard and TRICARE Extra or TRICARE For Life, there is no coverage (except for well-child benefit and diabetic patients, see later in figure).
  • Medically necessary care for injuries to the eye is covered.
Well-Child Benefit
  • For all TRICARE-eligible infants and children up to age 6:
    • Infants may receive one eye and vision screening1  during routine exams at birth and at approximately 6 months of age under the well-child benefit. Use V20.2 for eye examinations under the well-child benefit.
    • Children may receive two pediatric routine eye examinations2  between the ages of 3 and 6 years under the well-child benefit (use V20.2).
Diabetic Patients Diabetic patients at any age are allowed one routine eye examination each calendar year.

Note: For TRICARE Prime enrollees, self-referral will be allowed for routine eye examinations since PCMs are incapable of providing this service (i.e., a Prime beneficiary will be allowed to set up his or her own appointment for a routine eye examination with any network optometrist or ophthalmologist). The V code can be used for the annual exam; however, if a medical condition is identified, use medical diagnosis current procedural terminology (CPT) codes.
Pap Smears V72.3
V76.2		 Annually for women over age 18 (younger, if sexually active). No PCM or Humana Military referral or copayment are required for TRICARE Prime beneficiaries who use network providers.
Proctosigmoidoscopy/
sigmoidoscopy		 V76.51
V82.89
V82.9		 Individuals at average risk for colon cancer: Proctosigmoidoscopy/sigmoidoscopy once every three to five years beginning at age 50. Individuals at increased risk for colon cancer: Proctosigmoidoscopy/sigmoidoscopy once every five years, beginning at age 40, for individuals with a first-degree relative diagnosed with a colorectal cancer or an adenomatous polyp at age 60 or older, or two second-degree relatives. Individuals at high risk for colon cancer: Annual flexible sigmoidoscopy, beginning at age 10 through 12, for individuals with known or suspected familial adenomatous polyposis.
Regular immunizations V20.2
(includes well-child check)		 Immunizations should be administered at age-appropriate doses as suggested by the current schedule of recommended vaccines by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices.

Note: Immunizations required for ADFMs whose sponsors have permanent change-of-station orders to overseas locations are also covered. You must include a copy of the sponsor’s change-of-station orders when filing the claim. TRICARE does not cover immunizations for personal overseas travel.
School physicals

Note: Sports-related physical exams are not a covered benefits) 		V70.0
V70.3
V70.5
V70.9
  • TRICARE-eligible dependents who are at least 5 years old and less than 12 years old may get physical exams that are required by schools in connection with enrollment as students in those schools. This benefit does not include physical exams that may be required by the school to participate in school sports. Physicals for children ages 12 and older are authorized only if the physical is required.
  • TRICARE Prime beneficiaries do not have copayments when using network providers.
  • TRICARE Standard and TRICARE Extra beneficiaries will pay the applicable cost-shares and deductibles.
Well-child visits V20.2
  • Includes routine newborn care, comprehensive health promotion (birth to 6 years) and disease prevention exams, vision and hearing screenings, height/weight/head circumference, routine immunizations (according to CDC guidelines), and developmental/behavioral appraisals (according to American Academy of Pediatrics®).
  • There are no copayments or cost-shares required for TRICARE Prime or TRICARE Standard and TRICARE Extra beneficiaries.
1 Infant screening includes visual acuity, ocular alignment, red reflex, and external examination.
2  Pediatric routine eye examination includes amblyopia and strabismus examination.

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Last Update: January 15, 2011