EM Coding Alert

Question: My doctor heard we can report 99211 with 85610 for prothrombin time checks and with lipid panel code 80061. Is reporting the 99211 correct?

Wyoming Subscriber

Answer: You should avoid routinely reporting 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services.) with prothrombin time and lipid panel tests.

A nurse may have a standard list of questions she asks the patient before taking the blood specimen, but that doesn’t qualify for 99211 by itself. Code 99211 is an E/M code, so to report the code, the provider should document performing a distinct E/M service beyond the usual work involved in a patient presenting for the lab test. See www.noridianmedicare.com/provider/updates/docs/incident_to_billing_99211_acro.pdf for some examples from Noridian.

Keep in mind that if the patient is having trouble with the medication that requires the registered nurse (not certified medical assistant or medical assistant) to consult with the cardiologist, resulting in initiation of medication changes and new dose recommendations, documentation will most likely support reporting the E/M code of 99211. If the cardiologist gets involved and performs a face-to-face service, the physician is likely to code a 99212 or higher as long as the service meets the E/M component requirements.

Some payers may cover 99363-99364 (Anticoagulant management for an outpatient taking warfarin …), but Medicare will not reimburse you separately for those codes.

Blood draw: You may be able to bill separately for the blood draw, depending on the payer, with a code such as 36415 (Collection of venous blood by venipuncture) or 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]).

Lab: If you perform the lab test, then you may report the lab code. The two tests that you mention, 85610 (Prothrombin time) and 80061 (Lipid panel), both appear on the list of CLIA waived tests. If your lab performs one of the approved kits or methods (such as Roche Diagnostics CoaguChek XS for 85610 or Alere Cholestech LDX for 80061) and operates with a CLIA certificate of waiver, you should bill Medicare and other payers using 85610-QW (CLIA waived test) and 80061-QW.

You can find a complete list of CLIA waived test codes, including a list of the approved commercially marketed tests at www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Categorization_of_Tests.html . Download the list of waived tests for the current list, which updates quarterly.