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Cardiology Coding Alert

Reader Question:

Protime Checks

Published on Sat Dec 01, 2001

Question: We purchased a CoumaChek machine to check prothrombin times and already have a Clinical Laboratories Improvement Act (CLIA) number. Can I bill the nurse visit 99211-25 and 36415, in addition to 85610-QW?

Oregon Subscriber
 
Answer: Code 85610 (prothrombin time) with modifier -QW (CLIA waved test) is correct.
 
As for 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), like any other E/M code there must be medical necessity for the nurse visit. If the nurse only takes the sample, 99211 should not be billed. If, however, the documentation indicates that the nurse evaluated the patient, asking questions about compliance with coumadin dosage and other health-status issues, and then made a determination based on the evaluation (such as whether the dosage should be continued or changed and when the patient should return for additional services),  99211 may be billed separately.
 
It is extremely unlikely that carriers will pay for the finger stick, whether coded 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]) for private payers or G0001 (routine venipuncture for collection of specimen[s]) for Medicare carriers. The fee schedule lists G0001 as a status X code: The fee schedule appendix notes that status X codes represent an item or service that is not in the statutory definition of physician services for fee schedule payment purposes. No RVUs or payment amounts are shown for these codes, and no payment may be made under the physician fee schedule.
 
Most Medicare carriers do not pay for finger sticks, although Trailblazer (the Part B carrier in Delaware, Maryland, Texas, Virginia and the District of Columbia) reportedly pays $3 for G0001 in such situations.
 
Note: The CLIA designation indicates that the cardiologist is spinning only a drop of blood, whereas a laboratory would use a vial of blood. Without the modifier, the carrier might assume the claim came from a laboratory because labs make up the bulk of 80000-series (pathology and laboratory) code claims.

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