Cardiology Coding Alert

Even if a payer covers new codes, you may not be able to use them -- here's why

If you're still eyeing those handy Coumadin codes CPT offered for 2007, you could find yourself in another sticky situation -- with a denial on your desk.

Here's What You Should Be Doing

You should keep using protime code 85610 (Prothrombin time), plus E/M code 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...) as appropriate, to bill for anticoagulation management, says Heather R. Stecker, CPC, director of compliance and charge entry at Cardiology Consultants of Philadelphia PC. At least, that's the advice her local carrier sent her.

Keep in mind: Because 85610 has no global period, you won't need to attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99211. Many payers (including some Medicare carriers), however, will not properly process a claim with 85610 and an E/M code unless you attach modifier 25 to the E/M code. More commonly, carriers will immediately audit claims containing 99211 and 85610 for the same patient and same date of service. Ask your payers what they prefer.

Look at but Don't Touch These 2007 Codes

Chances are Medicare payers won't prefer the new-for-2007 Coumadin codes.

Remember how providers were excited when CPT 2007 introduced two new codes to report outpatient management of warfarin sodium (an anticoagulant also known as Coumadin)? Here are the codes CPT gave you:

• 99363 -- Anticoagulant management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; initial 90 days of therapy (must include a minimum of 8 INR measurements)

• 99364 -- ... each subsequent 90 days of therapy (must include a minimum of 3 INR measurements). 

Bad news: But CMS dashed all your hopes of getting proper reimbursement for your Coumadin clinic. At first, CMS seemed poised to pay $100 for 99363 and $35 for 99364. But then CMS announced these codes would be Status B, or bundled, and thus non-covered for Medicare.

"When I first read about the new anticoagulant codes 99363 and 99364, I was very excited to know that finally there were some codes to acknowledge the work done in our Coumadin clinic," says Sarah Tupper, CMC, coder for Central New York Cardiology in Utica.

Coumadin management involves more than just a blood draw. "It's careful monitoring, return appointments, and counseling," Tupper adds. Many Coumadin patients have multiple problems.

But "once again, codes are dangled in front of the coders' noses, only to be yanked away just out of reach," Tupper says.

Think Twice About New Codes if a Nurse Is Involved

So now you know that for some payers you'll need to report 85610 as well as 99211 as appropriate, but that's not the end of the story.

Heads up: Even if a non-Medicare payer will cover 99363-99364, you can't bill them -- unless the physician supervises your Coumadin management directly. If a nurse performs the management, you should be billing 85610 and 99211 in any case, says Jennifer Crowell with Spokane Cardiology in Washington.

Also, you should bill 99211 for the nurse's time only when the nurse documents that the visit is not the "standard" Coumadin check visit. For example, the nurse should document other symptoms, such as bruising or bleeding, that needed more attention.

Remember: "You can bill an appropriate E/M only when a new symptom, complaint or complication arises,"  Tupper says.