Internal Medicine Coding Alert

Due to advances in medical technology, the manner in which Prothrombin time laboratory tests are administered, processed and evaluated has changed. Finger sticks instead of blood draws, electronically transmitted results and portable testing equipment have made it easier for internists to test patients and evaluate the results. Internists should be aware, however, that many of these procedures, such as finger sticks, are not reimbursed by Medicare.

Prothrombin time (Protime) laboratory tests are used to determine the length of time it takes for a specimen of prothrombin to induce blood-plasma clotting in a patient and are frequently used with patients who are on the medication Coumadin. Although the internist is usually not reimbursed for the laboratory test, he or she may be reimbursed for drawing the blood specimen required to do the test, says Kathy Pride, CPC, coding supervisor for Martin Memorial Medical Group in Stuart, Fla.

When reporting the blood draw for a Protime test to a commercial payer, internists should use 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]). When reporting the blood draw to a Medicare carrier, HCPCS code G0001 (routine venipuncture for collection of specimen[s]) should be used.

Many times a patient will have blood drawn that will be used for several tests. If a patient has high blood pressure, the internist may also order a potassium test at the same time, says Karen Cowan, office manager of Pine Tree Internal Medicine, an internal medicine practice with six internists in Farmington, Maine. A full chemistry profile or complete blood count might also be ordered. Because both the Medicare and CPT definitions stipulate the word specimen(s), however, the blood draw can be billed only once regardless of how many tests are run using the specimen.

Medicare Does Not Cover Finger Sticks

In addition to sending the specimen to a laboratory, internists now have the option of performing these Protime tests in their offices and processing the specimen themselves. A battery-powered photometer, for example, uses a blood specimen gathered through a finger stick instead of a venipuncture.

If the internist processes the specimen in the office, then he or she should be reimbursed for the test by reporting 85610 (Prothrombin time) to the payer, Pride says. In addition, 36415 can be used to report the finger stick to a commercial payer. No modifier needs to be added to either code.

The fingerstick is not reimbursable by Medicare, however, and the internist can bill only for the test. The definition for G0001 does not include finger, heel or ear sticks because Medicare considers these to be incidental, Pride explains.

Evaluation of Results Not Separately Reportable

Even when the test is processed by an outside lab, there is still a lot of evaluation and updating by the internist after the test results are received. Coumadin patients are different; they require more evaluation, notification and reminders, Cowan says. Thats because when the Coumadin is not thinning the blood enough, the patients dont know it. They dont feel any different.

At Cowans practice, which has about 100 patients who are on Coumadin and regularly receive Protime tests, the test results are electronically transmitted back to the internist by the hospital that processes the tests. (Critical results are communicated by phone from the hospital to the internist.) The test results then have to be transcribed by a staff person to an index card that is kept on each Coumadin patient. The transcribed results are evaluated by an internist or a nurse, who compares the actual clotting times to an acceptable range of clotting times that were previously established by the internist. If the test result is different than the goal, the patients medication may have to be adjusted, Cowan says. We may have to call the patient and ask them to come into the office.

Despite all of the transcribing and evaluating, Cowans practice does not charge an extra evaluation and management (E/M) service for this work. We dont bill for a review of results, she says. We believe that the patient has a right to know the results of their lab test.

Pride agrees that it is not appropriate to bill for even the lowest level of E/M service, 99211. You cant bill for a review of test results that were faxed to the internist. There has to be face-to-face contact in order to report an E/M service, she says. This is a potentially fraudulent use of code 99211.

This review of the test results, however, could be applied to the patients next office visit and could be considered when determining the level of E/M service to report for that next visit. The review of test results is part of the amount and/or complexity of data to be reviewed, which is an element in determining the complexity of medical decision-making that occurred, Pride says.

Report Separate E/M Service With Blood Draw

The internist may also be able to report an E/M service in addition to the Protime blood draw. If the patient doesnt see the internist and he or she just has blood drawn, we dont bill for an E/M service, Cowan says. But the internist may spend some time talking with the patient about what their Coumadin dosage should be, how this will prevent them from having another stroke and the importance of having regular Protime tests, and we will report that discussion with an E/M code.

Check Local Policy For Diagnosis Code

Internists should consult their local medical review policy (LMRP) regarding the appropriate diagnosis code to report with any services associated with the Protime test because these will vary significantly from carrier to carrier. The internist needs to use a specific diagnosis code that is covered by the carrier or payer, Pride says. We frequently use V58.61 (long-term [current] use of anticoagulants) for patients who are on Coumadin.

It may be trickier to determine an appropriate diagnosis code for Protime tests administered as part of a preoperative examination. According to Pride, Florida Medicare will accept V72.84 (pre-operative examination, unspecified) as a diagnosis code for this type of examination. However, many other payers may not accept that diagnosis code and require internists to report a diagnosis that describes the patients specific signs and symptoms.