# Coumadin follow-up visits



## CardioCoder79 (Mar 10, 2014)

Is anyone billing anything other than 99211 for their coumadin checks? I'm wondering if the physician sees the patient and the documentation is sufficient, can a level 2 or 3 be billed for every check?


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## jkraning (Mar 10, 2014)

*Coumadin Level*

We bill a level 2 with our NP seeing the pt unless the Coumadin check is abnormal then possibly a level 3. I would only bill a level one is the pt is seeing a staff member, ect. Good luck


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## mitchellde (Mar 10, 2014)

if the patient presents for a pre scheduled service and there is no reason to have anything in addition, in other words the labs are normal and there are no patient complaints then there can be no visit level provider or otherwise.  Just like you cannot charge a 99211 for a blood draw encounter you cannot charge a 99212.  If the level is abnormal and the provider sees the patient as a result then yes you may charge an encounter.


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## Misty Dawn (Mar 10, 2014)

It is appropriate to bill for the nurse visit during a pro-time if the below instructions are meet: 

Code 99211 is defined in the Current Procedural Terminology code book as: "Office or other outpatient visit for the [E/M] of an established patient that may not require the presence of a physician. Usually the presenting problem(s) are minimal. Typically 5 minutes are spent performing or supervising these services." 

All E/M requirements must be met, including the following: 

?The patient is established, with a physician's plan of care in place for the presenting problem. When treating patients whose care is covered by Medicare, "incident-to" guidelines must be met.
?Separate documentation and medical necessity for this service (in addition to an injection or other service) must be included in the chart. The record needs to show how the nurse evaluated and/or managed the patient. Because these visits are short and nurses many times go from one patient to the next, documentation does not always find its way into the chart.
?Minimally necessary documentation could include the reason for the visit, a brief history and/or vital signs, the education provided, and/or a brief assessment. The note also should include the date of service, the identity of the nurse providing the service, and information about any verbal interaction with the physician, whose identity also should be noted.
?Face-to-face contact between the nurse (or physician) and the patient must be documented in the chart. Some coders erroneously believe that 99211 is only for nurse visits when, in fact, physicians can bill 99211 on those rare occasions when documentation doesn't meet the requirements for a higher-level established patient E/M code.


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## mitchellde (Mar 10, 2014)

You cannot bill a visit level of any flavor when the patient presents for a scheduled service and a code exists for that service.  This is no different than a patient that presents for a scheduled joint injection, the provider cannot bill an office visit only the injection.  Therefore when a patient presents for a scheduled blood draw then you can bill only the blood collection code.  Taking vitals is an integral part of the blood draw encounter.


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## Misty Dawn (Mar 11, 2014)

no the E/M is not included in 85610 these are different then joint injection due to the continued follow up, monitoring and counseling.   

"Physicians can bill CPT 99211 when a nurse (or other office personnel) meets with a patient in the office to discuss the prothrombin time test results and schedule the next test. To bill using CPT 99211, the physician does not have to be present, but should be available if needed."

We have a comidian clinic set up in our office (average about 80 pts a month) and do bill for the 99211 when our nurses dictation meets the above criteria that posted in this and above guidelines. Usually Blood pressure results,  a short statement on what the pt was counseled on (example: home testing, diet, afib and notes the time spent on counseling",  Taking blood pressure, discussions on diet, bleeding hx since last seeing.... are not included in 85610.  This is supported in the CPT, and most payer policy including Noridian and Medicare.


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## OCD_coder (Mar 11, 2014)

I am in agreement with Debra on this topic.  The 85610 has a brief history (obtaining vitals) and exam component as part of the procedure as the global status code is XXX.  Per the CMS guidelines in the NCCI Coding Policy Manual, General Coding Policies, Chapter 1. (eff. Jan. 1, 2014)

_This E&M service may be related to the same diagnosis necessitating performance of the ?XXX? procedure but cannot include any work inherent in the ?XXX? procedure, supervision of others performing the ?XXX? procedure, or time for interpreting the result of the ?XXX? procedure. _ - CMS

*Novitas-*An evaluation and management (E/M) service (99211) *would be allowable if *it is determined that the patient's medication needs adjustment, the INR is not therapeutic, or if the patient has symptoms that need to be addressed. 

The billing of an E/M service in addition to obtaining the clinical specimen (phlebotomy or finger stick) is not medically reasonable and necessary if the following conditions are met: 

If the INR is within the therapeutic range, and 

1. the documentation does not support a need for adjustment of warfarin dosage, or
2. the documentation does not support that the patient is symptomatic, or
3. the documentation does not support the presence of a new medical co-morbidity or dietary change. 
Rather, information may be relayed to the beneficiary telephonically, and there is no need for a face-to-face E/M service.

http://www.novitas-solutions.com/webcenter

*Noridian* "might" allow it per their guidelines.  This would need to be a facility decision to allow billing for nursing work prior to an INR check performed in the office.
https://www.noridianmedicare.com/provider/updates/docs/incident_to_billing_99211_acro.pdf


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