Cardiology Coding Alert

Don't miss: Counseling services can sometimes mean an E/M code

Patients using warfarin (brand name Coumadin) for chronic atrial fibrillation and venous thromboembolism can rejoice. CMS opened the door to new payment rules governing prothombin time testing, and this time, the new rules expand coverage, rather than restrict it.

In the past: Before this revision to Medicare's National Coverage Determination (NCD), Medicare allowed home testing coverage only for beneficiaries with mechanical heart valves who took warfarin.

The agency instructed carriers to implement the new policy by Aug. 25 in Transmittals 90 and 1562, both dated July 25.

Delve Into the New Policy

Under the new policy, "the patient would have to first be anticoagulated for three months or longer before implementing home monitoring," says Nicole Smith, CPC-CARDIO, E/M, a coder at Spokane Cardiology in Wash. "Education has to be provided to the patient about how to use the monitoring device, and home testing shouldn't be done more than once a week," she says.

Keep in mind: You can collect for the patient education session when teaching the patient how to use the home monitoring device. "The 2008 HCPCS Level II manual describes these services in depth," says Christina Neighbors, MA, CPC, ACS-CA, charge capture reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash. Those codes are as follows:

• G0248 -- Demonstration, at initial use, of home INR monitoring for patient with mechanical heart valve(s) who meets Medicare coverage criteria, under the direction of a physician; includes demonstrating use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing (Initial service/charge)

• G0249 -- Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meets Medicare coverage criteria, includes provision of materials for use in the home and reporting of test results to physician; per four tests (Additional service/charge per four tests)

• G0250 -- Physician review, interpretation and patient management of home INR testing for patient with mechanical heart valve(s) who meets other coverage criteria; per four tests (does not require face-to-face service).

You'll find a new list of diagnosis codes that constitute medical necessity. Accepted ICD-9 codes include:
 • 289.81 -- Primary hypercoagulable state
 • 415.11-415.19 -- Pulmonary embolism and infarction
 • 427.31 -- Atrial fibrilation, established, paroxysmal
 • 451.0-451.9 -- Phlebitis and thrombophlebitis
 • 453.0-453.3 -- Other venous embolism and thrombosis
 • V43.3  -- Organ or tissue replaced by other means; heart valve.

In some cases, the patient may present to the practice for testing rather than perform the test at home, which you should code differently.

Many physician offices have a designated area called a "Coumadin clinic" where the nurse can assess the patient's clotting time using a lab test that you'll report with 85610 (Prothrombin time), Smith says. "For most patients, this is performed every four to six weeks. The test data will show if clotting time has fallen below the target range medication, then dosing is increased," Smith says. "When it goes above the target range medication, then dosing is decreased."

In some cases, the physician will need to counsel the patient on other factors that can impact clotting, such as exercise, diet and other medications. "Sometimes it is appropriate to report a low-level E/M visit code, 99211, with lab test code 85610 if there is medical necessity," Smith says. "Your documentation must state that the patient had a specific problem, as well as any complaints or signs and symptoms."

Consider This Example

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, although 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 physician. In this case, documentation would support medical necessity for 99211 as well as 85610.

Keep in mind: As the saying goes, the devil is in the details. If you are audited, many payers will not reimburse for the nurse visit -- unless the medical record establishes medical necessity for an office visit. This documentation must include the history, exam and medical decision making the nurse performed.

To read Medicare's new coverage decision, visit the CMS Web site at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=209.