Pathology/Lab Coding Alert

Avoid G0250 frequency pitfall.

In addition to ordering a Prothrombin Time (PT) lab test, physicians might ask certain patients to perform home PT monitoring to manage warfarin (trade name Coumadin) dosage.

When patients perform the test at home to determine the PT reading (in seconds) and/or the International Normalized Ratio (INR), you'll need to know a whole different set of coverage rules and codes than you read about in "3 Tips Show You How to Correctly Code PT Lab Tests" on page 75. Here's the lowdown on these services:

Look at Coverage and Coding

In addition to the lab NCD for PT testing (190.17), Medicare provides a distinct NCD, 190.11 (Home PT/ INR) for home testing. Unlike coverage for the lab test that is broadly supported as medically necessary for many conditions, CMS limits coverage for home PT/INR monitoring to patients with specific conditions who are taking warfarin. The covered conditions are mechanical heart valve, chronic atrial fibrillation, or venous thromboembolism. The case must also meet the following conditions to be eligible for Medicare coverage:

• A treating physician must prescribe home PT/INR monitoring
• Patient must have been anticoagulated for at least three months
• Patient must participate in face-to-face educational program on anticoagulation management and demonstrate correct device use
• Patient should not self-test more than once a week.

Hint: Local Medicare contractors may cover the service for a broader range of conditions, such as warfarin monitoring for patients with porcine heart valves. Always check coverage rules with your individual payers.

Use these codes: You have the following three codes to describe home PT/INR management for Medicare beneficiaries:

• G0248 (Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results)
• G0249 (Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests)
• G0250 (Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests)

Avoid Common Payment Snags

You can see that codes G0248 and G0250 require the service of a physician (or qualified healthcare provider). For instance, a pathologist may perform these tasks as part of a "Coumadin Clinic" to monitor coagulation therapy for patients.

Watch frequency: Medicare provides limitation for how often you can use each of the codes to bill for the service. You can report G0248 just once in a patient's lifetime, while you can bill G0249 and G0250 once every four weeks.

Specifically: Physicians should only bill G0250 once every 28 days. If the physician submits G0250 before the 28 full days have passed, Medicare will deny your claim.

Pitfall: Many physicians want their patients to perform the test more frequently than once per week when the test result isn't optimal (too high or low), according to Ray Cathey, PA, FAAPA, MHS, MHA, CCS-P, CMSCS, CHCI, CHCC, president of Medical Management Dimensions in Stockton, California. If the provider bills G0250 with the understanding that the code is "per four tests" without the caveat that the test is covered once per week, that can lead to claims denials.

Even if the patient performs the test more often than once per week per the physician instructions, you can expect payment for the testing only once every 28 days.

Management tip: Meeting the time restriction for G0250 is essential, but how can you make sure you're on the right track? "Since Medicare has specific timing parameters for the coverage of HCPSC code G0250, the frequency limitation information should be shared with the practitioners and billing staff to assist in operational billing and reimbursement processes," says Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska.

"Consider incorporating flags/edits in the billing software for G0250 to help ensure 28 full days have passed (not occurring more than once a week, billing units of service include four weeks), to avoid claim denials," Swanson suggests.

Swanson also recommends that practices implement an internal policy and procedure for reporting G0250 outlining Medicare's coverage, billing, and reimbursement policy.

Qualified personnel: Staff other than the physician may obtain test results from the patient, but the physician must review and interpret the results, according to Cathey. "These test results must be documented in the patient record," Cathey says. "It is recommended that the physician acknowledge his/her review of all test results thus documented."

Carefully Document Dx and Testing

Make sure the medical record demonstrates each component that indicates compliance with the payer coverage requirements.

Documentation for G0250 should include the following elements:

• date of test
• diagnosis of a covered condition, such as I48.2 (Chronic atrial fibrillation)
• the target INR range
• the patient test result.

"Additionally, medical record documentation should support the physician's order, test result review, interpretation, and patient management of home INR testing," Swanson says.

Patient instructions: Be sure to document communicating the test interpretation, and any medication changes, to the patient or representative.

"I would also suggest that the statement include a comment such as 'the patient (or representative) appears to understand' the new instructions," Cathey says. "And the physician review/signature is required."