Cardiology Coding Alert

Question: When should I use the new testing code for warfarin (G9143)?

Wisconsin Subscriber

Answer: You should report G9143 (Warfarin responsiveness testing by genetic technique using any method, any number of specimen[s]) only if you're reporting the actual testing to see how a patient's genetic makeup affects the body's response to warfarin, also called pharmacogenomic testing. So a lab is likely to report this code.

Background: As of Aug. 3, 2009, Medicare covers pharmacogenomic testing to predict warfarin responsiveness only "in the context of a prospective randomized, controlled clinical study when that study meets certain criteria as outlined in the Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 90.1," states MLN Matters article MM6715 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6715.pdf).

According to the article, testing is covered if the beneficiary meets three conditions:

1. Is a candidate for anticoagulation therapy with warfarin

2. Has not been previously tested for CYP2C9 or VKORC1 alleles (the alleles warfarin responsiveness is limited to)

3. Has received fewer than five days of warfarin in the anticoagulation regimen for which the provider orders testing.

Medicare covers the test only once in a beneficiary's lifetime, "unless there is a reason to believe that the patient's personal genetic characteristics would change over time," the article states.

Practitioner claims for the testing should identify the service using the following :

V70.7 -- Examination of participant in clinical trial 8-digit clinical trial number (when present on the claim) modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study)

G9143.