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Internal Medicine Coding Alert

Is Your Office Getting Stuck? Increase Reimbursement With a Coumadin Coding Checkup

Published on Thu Aug 01, 2002

Coding differs when practices use in-office finger stick devices rather than outside laboratories to monitor Coumadin patients, and you may find you can show medical necessity to support billing 99211 (which pays about $20 nationally) in addition to the test code.

Coumadin Patients Require Careful Monitoring

Coumadin, or warfarin sodium, is a blood thinner used to prevent heart attacks, strokes and complications from other disorders, such as deep venous thrombosis and atrial fibrillation. However, because too much Coumadin can lead to serious, even fatal bleeding, patients must undergo careful monitoring. Until recent years, physicians typically monitored a Coumadin patient by regularly sending a blood sample to an outside laboratory for a prothrombin time (Protime) test to determine the international normalized ratio (INR), or how long it takes the blood to clot.

But now, devices are available that measure blood clotting speed with a sample taken from a simple finger stick. Many offices use these devices to check their patients' levels in the office, giving the physician almost instant results and making it possible to adjust medication on the spot.

Put Your Finger on the Right Codes

Many coders are confused about how to correctly code Coumadin monitoring with in-office devices:

  • Can I use G0001 or CPT code 36415 for the finger stick?

    If the patient is on Medicare, like the great majority of Coumadin patients, the answer is no. Medicare will not pay for a heel, ear or finger stick. HCPCS code G0001 (Routine venipuncture for collection of specimen[s]) is specifically for venipuncture, or blood samples taken via needle from a vein. (Use G0001 only if your office still takes blood samples from a vein and sends the patient's blood to an outside laboratory for analysis of Coumadin levels.)

    If the patient having the in-office Protime test is covered by private insurance, you may be able to bill 36415 (Routine venipuncture or finger/heel/ear stick for collection of specimen[s]) for the finger stick. Check with the carrier for more information.

  • How should I code the in-office, finger stick Protime lab test for a Medicare patient?

    Use 85610 (Prothrombin time). Most carriers also ask that you append the -QW modifier (CLIA-waived test) to indicate that CMS has included the test on a list of procedures that do not have to meet the requirements of the Clinical Laboratory Improvement Amendments Congress passed in 1988. Even though the finger stick Protime is a CLIA-waived test, you must still report your practice's CLIA certificate number in box 23 of the HCFA 1500 claim form (or in the equivalent field position for electronic submitters).

    Note: Visit the Web site http://www.cms.hhs.gov/ clia/cliaapp.asp for CLIA application information.

    Make sure the manufacturer's test you are using is on your local Medicare carrier's list of approved CLIA-waived tests, says Lisa Johnson, CPC, CCS-P, senior consultant at Gates, Moore & Company in Atlanta.

  • Can we charge a low-level E/M, such as 99211, in addition to the finger stick Coumadin test?

    "Simply doing the finger stick or performing the test would not be sufficient to use 99211," Johnson says. But you may use 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) along with 85610-QW when there is clearly documented medical necessity for an E/M visit. If the nurse assesses the patient, reviews the Coumadin dosage, and provides information to the patient such as when to return for another Protime, when to follow up with the physician, and to call if unusual bruising occurs or blood is seen in the urine and this is documented that would be sufficient to code 99211, Johnson says.

    Maria Coslett, CPC, office manager for Sreenivasa Alla, MD, an internist in Port St. Lucie, Fla., says her office almost always codes 99211 in addition to 85610 because of the complexity of the encounter with the patient who comes in for Coumadin monitoring.

    Besides performing the finger stick and running the test, the nurse typically invests significant time in discussing medication, patient health status and other issues, Coslett says. Since moving to the in-house tests several years ago, her office has developed a form with places to record Protime results, current medication levels, recommended new levels and answers to a series of questions the nurse asks on each visit. These include questions about the dosage the patient is taking and whether he or she has had bleeding, bruising or other symptoms that can be related to the drug.

    Even though the form notes the patient's dosage, Coslett says the nurse also asks the patient how much medication he or she is taking because Coumadin dosages can confuse patients.

    For example, suppose a 75-year-old male patient comes in for Coumadin monitoring. During questioning, the nurse discovers that he has been taking a 5-mg tablet daily, though his prescription calls for a 5-mg tablet on Mondays, Wednesdays and Fridays and a 7.5-mg tablet the other days. The nurse not only monitors his Coumadin levels to determine this lapse's effect but also counsels the patient on Coumadin's proper administration after confirming dosages with the physician. In this case, documentation would support medical necessity for 99211 as well as 85610-QW.

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