# Billing for Protimes



## cmontgomery (Nov 14, 2014)

We do Protimes (85610) on patients taking coumadin in our office.  We used to just bill out 99211, 85610-QW and 36415-59 with a diagnosis of v58.61.  The nurse would complete a med list review, perform a complete set of vitals and question the patient regarding bleeding, bruising etc.  We were paid with no problems.  Suddenly just recently Novitas will not pay for the 99211 as they state it is included with the 36415 and they stated to append a mod 25 to the 99211.  Since they stated that, we started adding the primary reason the pt was on the coumadin, say 427.31, linking the 99211-25 to that dx code and linking the 85610-QW and 36415-59 only to the v58.61.  I didn't want to add a mod25 but even when linking with its own diagnosis code, they stated it would not be paid without the modifyer.  Can anyone out there advise me if this is correct or how would you do it differently?  This case scenario is the only time we bill a 99211 as it stated in CMS guidelines previously that this would be acceptable when doing protimes in office.


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## cynthiabrown (Nov 14, 2014)

would like to see where cms says ok to bill nurse visit...........don't see where 25 mod is applicable. and should you not use 36416 finger stick with protime


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## Leenahz (Nov 24, 2014)

Whaaaa?  They want a 25 mod with 99211?  Never heard of that one.  Also, never heard of adding a 59 to a 36415 either.  I've had no problems with this billing:  99211, 36415, 85610QW all linked to a 286.9/V58.61 diagnosis.  

You can use 36416 if a finger stick was done, but some offices obtain by blood draw through a vein (36415).  I don't think Medicare will cover the 36416, however.

Lena


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## mitchellde (Nov 24, 2014)

Leenahz said:


> Whaaaa?  They want a 25 mod with 99211?  Never heard of that one.  Also, never heard of adding a 59 to a 36415 either.  I've had no problems with this billing:  99211, 36415, 85610QW all linked to a 286.9/V58.61 diagnosis.
> 
> You can use 36416 if a finger stick was done, but some offices obtain by blood draw through a vein (36415).  I don't think Medicare will cover the 36416, however.
> 
> Lena



You cannot use then25 modifier because you cannot meet the criteria of significant and separately identifiable encounter.  You should bill only the blood collection and the lab code if you run the lab in house.  Now the dx code of 286.9 is incorrect unless the provider diagnoses that the patient has a condition of coagulopathy but then they would not be on anticoagulant drugs.  The AMA and the AHA has stated on numerous occasions that anticoag drugs cannot give the patient the condition of coagulopathy. If this is not documented as the patient s diagnosis then the coder is rendering a diagnosis without the provider input.  Your dx codes should be V58.83 followed by V58.61.


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## cmontgomery (Nov 25, 2014)

Thanks for all of your input. I researched this further since putting a 25 on a 99211 seemed wrong to me.  I went to the Novitas website and they stated protimes billed with a 99211 can only be billed out if the patient is not at a therapeutic dosing level of coumadin.  You can print their guide sheet with the instructions.  Since we do the protimes inhouse with a fingerstick, we now just bill out a 99211 with the 85610-QW (for non-therapeutic levels) and since there is no blood draw collection (36416 not covered by MCR) there is no modifier issue related to the claim and it is paid. For patients that have reached a therapeutic level we are debating whether to even do them inhouse since we can only get paid for a 85610-QW and we all know that doesn't cover the time involved with documentation, flow sheets etc.  We use the V58.61 and the original dx for the reason the patient is on the blood thinner as well.  Isn't it odd that they would state to put the mod on a 99211 anyway?  Go figure....


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