Medicare Compliance & Reimbursement

Stick with 85610 and 99211 for Coumadin management.

Providers were excited when CPT 2007 introduced two new codes to report outpatient management of warfarin sodium (an anticoagulant also known as Coumadin):

· 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]).   

Bad news: But the Centers for Medicare & Medicaid Services (CMS) dashed all your hopes of getting proper reimbursement for your Coumadin clinic. At first, CMS seemed poised to pay $100 for 99364 and $35 for 99364. But then CMS announced these codes would be Status B, or bundled, and thus non-covered for Medicare.

"When I first read about the new anticoagulant codes 99363 and 99364, I was very excited to know that finally there were some codes to acknowledge the work done in our Coumadin clinic," says Sarah Tupper with Central New York Cardiology in Utica.

Coumadin management involves more than just a blood draw. "It's careful monitoring, and return appointments, and counseling." Many Coumadin patients have multiple problems besides afibrillation.

But "once again codes are dangled in front of the coders' noses, only to be yanked away just out of reach," she frets.

What to do: You should keep using protime code 85610, plus evaluation and management code 99211 as appropriate, to bill for anticoagulation management, says Heather Stecker, reimbursement manager with Cardiology Consultants of Philadelphia. At least, that's the advice her local carrier sent her.
 
Note: You can't bill for 99363-99364 even if a payor will cover them, unless the physician supervises your 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.

You should only bill a 99211 for the nurse's time 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 that needed more attention.

Remember: "You can only bill an appropriate E/M when a new symptom, complaint or complication arises," says Tupper.

CMS should either start paying the new codes--and allow nurses to bill them--or increase the low fee for 85610, Tupper maintains.

So far, no other payors seem to be reimbursing 99363-99364, experts say.