Oncology & Hematology Coding Alert

Medicare carriers can no longer deny claims based on frequency limits unless they publish a national policy or LMRP defining the interval of "reasonable" frequency. Many LMRPs limit the frequency of PT testing to once every four to six weeks for patients on stable warfarin, the anticoagulant drug found in Coumadin, Panwarfin and Sofarin.

However, carriers must now review medical documentation before they deny tests, even if those tests occur more frequently than their LMRPs dictate. Take a wide-awake approach to medical necessity for PT tests and you may recover reimbursement on frequently submitted tests that used to slip away.

The final rule states explicitly that if Medicare carriers find insufficient documentation of medical necessity, they are required to request the relevant parts of the patients records before they deny the claim. Coders should respond to those requests immediately, or Medicare can deny PT claims.