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Cardiology Coding Alert

Keep Reimbursement Flowing With Coumadin Coding Checkup

Published on Sat Mar 01, 2003

If you're not up to speed on two crucial aspects of Coumadin monitoring in-office finger stick coding and medical necessity to support billing 99211 you could be losing pay your practice deserves.

Cardiology practices use the blood thinner Coumadin, or warfarin sodium, to prevent clots in the heart and the vascular system, and complications from other disorders, such as atrial fibrillation. Clinical staff must carefully monitor patients taking Coumadin because too much Coumadin can lead to serious, even fatal bleeding.

Mechanical-valve patients require even more intensive monitoring because they take 2.5 to 3.5 times more Coumadin than other patients do, says Jim Collins, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C., and compliance manager for Mid Carolina Cardiology in Charlotte, N.C.

Until recently, physicians monitored a Coumadin patient by regularly sending a blood sample to an outside laboratory for a prothrombin time (Protime) test to determine the international normalized ratio (INR), or how long it takes the blood to clot.

But now, devices are available that measure blood clotting speed with a sample taken from a simple finger stick. Many practices use these devices to check their patients'levels in the office, giving the cardiologist almost instant results and making it possible to adjust medication on the spot.

Beginning in 2003, cardiology practices will be able to monitor mechanical heart valve patients on Coumadin from home, Collins says. (For coding instructions on in-home Coumadin monitoring, see next month's Cardiology Coding Alert.)

Don't Get Stuck With Old Codes

If you're wondering how to correctly code Coumadin monitoring with in-office devices, taking a look at the following four questions and answers will fill in knowledge gaps.

  • Can I use G0001 or 36416 for the finger stick?

    If the patient is on Medicare, like most Coumadin patients, the answer is no. Medicare will not pay for a heel, ear or finger stick. HCPCS code G0001 (Routine venipuncture for collection of specimen[s]) is specifically for venipuncture, or blood samples taken via needle from a vein. (Use G0001 only if your office still takes blood samples from a vein and sends the patient's blood to an outside laboratory for Coumadin-level analysis.)

    If the patient having the in-office Protime test is covered by private insurance, you may be able to bill 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]) for the finger stick. Check with the carrier for more information.

  • How should I code the in-office, finger-stick Protime lab test for a Medicare patient?

    Use 85610 (Prothrombin time). Most carriers also ask that you append the -QW modifier (CLIA-waived test) to indicate that CMS has included the test on a list of procedures that do not have to meet the requirements of the Clinical Laboratory Improvement Amendments Congress passed in 1988.

    Even though the finger-stick Protime is a CLIA-waived test, you must still report your practice's CLIA certificate number in box 23 of the CMS 1500 claim form (or in the equivalent field position for electronic submitters).

    Make sure the manufacturer's test you are using is on your local Medicare carrier's list of approved CLIA-waived tests, says Lisa Johnson, CPC, CCS-P, senior consultant at Gates, Moore & Company in Atlanta.

  • What diagnosis codes should I use?

    To report the primary diagnosis for Coumadin, you'll need to know the medical reason the patient is having the test. Often, the primary diagnosis code for Coumadin monitoring is V58.61 (Long-term [current] use of anticoagulants). When you use that code as the primary diagnosis, you may also include a secondary diagnosis code to indicate the reason the patient is on Coumadin, such as 427.31 (Atrial fibrillation). Be sure the diagnoses listed on the claim form reflect what is documented in the medical record regarding the reason for the visit and/or the service billed.

  • Can we charge a low-level E/M, such as 99211, in addition to the finger-stick Coumadin test?

    "Simply doing the finger stick or performing the test would not be sufficient to use 99211," Johnson says. But you may use 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) along with 85610-QW when the cardiologist has clearly documented medical necessity for an E/M visit.

    Reporting code 99211 depends on what services the physician provides during the visit, says Cynthia Swanson, RN, CPC, a cardiology coding consultant with Seim, Johnson, Sestak and Quist in Omaha, Neb.

    The nurse-only services must be medically necessary, and documentation must support that the services were performed and identify who performed them, Swanson says. For example, if the nurse provides such services as taking the patient's vital signs, checking for bruising, discussing medication compliance, giving dietary instruction, and then documents these services, you can bill 99211.

    In most cases, cardiology practices use code 99211 in addition to 85610 because of the complexity of the encounter with the patient who comes in for Coumadin monitoring.

    For instance, a 75-year-old male patient who has atrial fibrillation comes in for Coumadin monitoring. During questioning, the nurse discovers that he has been taking a 5-mg tablet daily, though his prescription calls for a 5-mg tablet on Mondays, Wednesdays and Fridays and a 7.5-mg tablet the other days. The nurse not only monitors his Coumadin levels to determine this lapse's effect but also counsels the patient on Coumadin's proper administration after confirming dosages with the cardiologist. In this case, documentation would support medical necessity for 99211 as well as 85610-QW.

    Occasionally, a Coumadin patient needs to see the cardiologist for a complication, such as bleeding. Or perhaps the patient has come in for an unrelated problem, and it's also time for the in-office Protime test. In both of those cases, you should code the appropriate-level E/M visit for the physician encounter (for example, 99212) and 85610-QW for the Coumadin monitoring.

    Because many patients on Coumadin are Medicare beneficiaries, check for any local medical review policies (LMRPs) that pertain to Prothrombin time (PT) testing (85610) and 99211 visit services, Swanson says.

    Code Repeat Finger Sticks for Inconclusive Tests

    If a patient's in-office test results are markedly different from what the cardiologist would expect considering the patient's dosage and symptoms, he or she may order a repeat finger-stick Protime performed in the office on the same day. In this case, the office would bill an additional 85610-QW with modifier -91 (Repeat clinical diagnostic laboratory test).

    Sometimes a physician orders an outside or reference laboratory analysis to confirm the in-house test. The reference laboratory would bill for performing the test. If the office staff draws the blood specimen for the lab, however, you would code this procedure with G0001 for a Medicare patient or 36416 for a patient covered by a private carrier.

    You may need to append modifier -59 (Distinct procedural service) to indicate to the payer that the venipuncture was a separate procedure from the CLIA-waived test, Johnson says. If the venipuncture is performed on the same day as the in-office Protime test, you would also code the finger-stick test with 85610-QW and, if the visit meets the documentation requirements, the appropriate E/M code.

    Editor's note: Visit the Web site http://www.cms.hhs.gov/clia/cliaapp.asp for CLIA application information.

     

     

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