EM Coding Alert

Question: Can you explain the anticoagulant management codes to me? Are they billable and how do you bill them along with an E/M code?

South Dakota Subscriber

Answer: According to CPT^®, “Anticoagulant services are intended to describe the outpatient management of warfarin therapy, including ordering, review, and interpretation of International Normalized Ratio (INR) testing, communication with patient, and dosage adjustments as appropriate.” An anticoagulant is a drug that prevents clot formation within the blood vessels and dissolves any previously formed blood clot.

Your anticoagulant management code options are as follows:

• 99363, Anticoagulant management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; initial 90 days of therapy (must include a minimum of 8 INR measurements
• 99364, … each subsequent 90 days of therapy (must include a minimum of 3 INR measurements.

You should only use the CPT^® codes 99363 and 99364 for outpatient services. When you report 99363 or 99364, “the work of anticoagulant management may not be used as a basis for reporting an evaluation and management (E/M) service or care plan oversight time during the reporting period,” according to CPT^®. However, if the physician performs a separately identifiable E/M service, you may report the appropriate E/M service code and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). In other words, the documentation for the anticoagulant management should stand on its own, as should the E/M service. When they are separate and significant, both are reportable.

You should never report 99363 or 99364 with the following codes when they address anticoagulation with warfarin management:

• 98966-98968, Non-face-to-face nonphysician telephone services
• 98969, Online medical evaluation
• 99441-99444, Non-face-to-face telephone services.

Also, never report 99363 or 99364 with the following or other code(s) for physician review, interpretation, and patient management of home INR testing for a patient with mechanical heart valve(s):

• 99217-99226, Hospital observation services
• 99221-99239, Hospital inpatient services
• 99291-99292, Critical care services
• 99304-99318, Nursing facility services
• 99471-99476, Inpatient neonatal and pediatric critical care
• 99477-99480, Initial and continuing intensive care services.