Pathology/Lab Coding Alert

Question: If a nurse administers the prothrombin time test for patients coming for periodic coagulation monitoring (such as patients on prescription Coumadin [warfarin]), what codes can be used for the service? Can we report 85610 for the lab test, 99211 for the nurses service, and 36415 for the fingerstick?

North Carolina Subscriber

Answer: The correct code for the prothrombin time lab test is 85610 (prothrombin time). Most providers limit how often the test can be performed for patients on anti-coagulation therapy such as warfarin. Check with your local provider for frequency provisions, which are usually about once every two to three weeks for stable patients.

Reporting an appropriate diagnosis code is also crucial for reimbursement of repeat prothrombin time tests. Use V58.61 (long-term use of anticoagulants) when that is the primary reason for the test. Coding past conditions that led to the anti-coagulation therapy, such as pulmonary embolism (415.1x) or deep-vein thrombosis (e.g., 453.8), may not indicate medical necessity for periodic testing.

Code 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) should not be used if the nurse only draws blood. Although the code is often used to bill services by a nonphysician practitioner because the definition states that the presence of a physician is not necessary, it cannot be used without meeting certain criteria.

Despite the fact that 99211 does not require the history, examination and medical decision-making components of most other E/M codes, it does state that Typically, 5 minutes are spent performing or supervising these services. This means that to report 99211, the nurse must spend several minutes evaluating and managing the patients condition.

For example, 99211 could be reported if the nurse takes vital signs and discusses information about the patients condition such as change in diet or easy bruising of skin. It could also be used if the nurse discusses with the patient any problems and concerns that ordinarily would be addressed by the physician, such as present dosage of medication, or the continuation or change of dosage and monitoring. With a patient on long-term anticoagulant therapy in which the control is very stable, reporting this code may not be appropriate every time the patient is tested. Instead, just the 85610 would be correct because the nurse isnt spending as much time with the patient each visit.

Also, Medicare requires that there must be direct physician supervision of the 99211 incident to service for it to be billable. This means that although the physician does not have to be present in the room, he or she must be on site and be available to direct and assist. Even so, some local Medicare carriers do not reimburse for E/M services provided by a nurse.

Note that 99211 is on HCFAs audit watch list because it is so widely abused. Be sure to keep good documentation for this service. In fact, many carriers now require providers to list three vital signs to prove the visit took place.

If the nurse only draws blood, report the appropriate venipuncture code. For third-party payers, use 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]). For Medicare patients, report HCPCS code G0001 (routine venipuncture for collection of specimen[s]), as 36415 is not on Medicares laboratory fee schedule. However, note that if the nurse performs a CLIA-waived test (e.g., Protime) using blood from a fingerstick, G0001 may not be used, because it is limited to venipuncture. Also note that you may not report the venipuncture code in addition to an E/M code for the nurse visit if that service is provided.

Answered by William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, laboratory coding and compliance consultants in Longwood, Fla.