Internal Medicine Coding Alert

Some coders may have been overly optimistic last year when CPT introduced new codes for managing warfarin sodium (an anticoagulant also known as Coumadin). But once coders started filing claims, the enthusiasm over the codes quickly turned to frustration.

The codes (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]; and 99364, ... each subsequent 90 days of therapy [must include a minimum of 3 INR measurements]) may have glittered at first, but medical practices across the country are realizing that 99363 and 99364 aren't exactly coding gold.--

Bottom line: No one is getting paid for them. They're on Medicare's "Status B" (bundled) list and are therefore not covered. And even if you've stumbled on a payer that does reimburse for them, you likely won't be able to use the codes if the nurse performs the management.

Worse, they could cause you compliance headaches. If you try to bill for them and bill for an E/M service during

the same period, carriers could construe that as double-dipping, Robin Linker, CPC, CPC-H, CPC-P, CCS-P, MCS-P, CHC, warned primary-care coders at the national AAPC conference in Seattle.

Here's Your Backup Plan

Continue using Protime code 85610 (Prothrombin time), plus E/M code 99211 (Office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent supervising these services) as appropriate, to bill for anticoagulation management, says Heather R. Stecker, CPC, director of compliance and charge entry at Cardiology Consultants of Philadelphia.

Breakdown: You'll report 85610 to capture the actual lab test performance for the prothrombin time. Code 99211 is to capture the services for the physician's test interpretation, management of the Coumadin dosage and patient education. At least, that's the advice Stecker's local carrier sent her.

Keep in mind: Because 85610 has no global period, you won't need to attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99211.

Many payers (including some Medicare carriers), however, will not properly process a claim with 85610 and an E/M code unless you attach modifier 25 to the E/M code. More commonly, carriers will immediately audit any claims containing 99211 and 85610 for the same patient and same date of service. Ask your payers what they would prefer.

Nurse Involved? Think Twice About New Codes

So now you know that for some payers you'll need to report 85610 as well as 99211 as appropriate, but that's not the end of the story.

Heads-up: Even if a non-Medicare payer will cover 99363-99364, you can't bill them -- unless the physician supervises your patients' Coumadin management directly. If a nurse performs the management, you should be billing 85610 and 99211 in any case, says Jennifer Crowell with Spokane Cardiology in Washington.

Also, you should bill 99211 for the nurse's time only when the nurse documents that the visit is not the "standard" Coumadin check visit. For example, the nurse should document other symptoms, such as bruising or bleeding, which needed more attention.