Pathology/Lab Coding Alert

Although you can't use 85610 (Prothrombin time) for home PT monitoring, you can charge for certain associated services provided the patient meets Medicare's new criteria.

Medicare has covered home PT/INR monitoring for anticoagulation management in mechanical heart valve patients since 2001.

More recently, CMS stated that Medicare will also cover patients on warfarin therapy who have chronic atrial fibrillation, venous thromboembolism (including deep venous thrombosis), or pulmonary embolism. CMS updated the list of covered ICD-9 codes for home PT/INR monitoring in Feb. 2009 (effective retroactively to March 19, 2008) to include the following:

- V43.3 -- Organ or tissue replaced by other means;heart valve

- 289.81 -- Primary hypercoagulable state

- 415.1x -- Pulmonary embolism and infarction

- 427.31--Atrial fibrillation

- 451.0-451.9 --Phlebitis and thrombophlebitis

- 453.0-453.3 -- Other venous embolism and thrombosis

- 453.40-453.9 (includes 453.40-453.42, 453.8- 453.9) -- Venous embolism and thrombosis of deep vessels of lower extremity.

Count only mechanical valves. The expanded coverage doesn't extend to PT/INR home monitoring for patients on warfarin following porcine heart valve replacement.

To make sure the patient qualifies for the home PT/INR home monitoring based on CMS guidelines, use the following checklist:

A physician prescribes the home monitoring

Anticoagulation therapy has been in place for at least three months prior to implementing home monitoring

Patient receives training in how to use the monitoring device

Patient performs the test no more than once a week.

You should not report 85610 for the home monitoring test. The patient performs the home monitoring, and you can't charge for that.

Do this: Instead, you should report the service you provide at an encounter with a home-monitoring patient using the appropriate code from the following list:

- G0248--Demonstration, prior to initial use, 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 ...

- G0249--Provision of test materials and equipment for home INR monitoring to 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; not occurring more frequently than once a week.

- G0250 -- Physician review, interpretation, and patient management of home INR testing for a patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes face-to- face verification by the physician at least once a year ... that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring; not occurring more frequently than once a week.

Don't miss: -Even in self-monitoring patients, physicians may order a laboratory PT test,- says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha. In those cases, you should still report 85610 for the test.

The PT laboratory National Coverage Determination states, -Current medical information does not clarify the role of laboratory PT testing in patients who are self monitoring.

Therefore, the indications for testing apply regardless of whether or not the patient is also PT self-testing.-

Bottom line: Coverage for home monitoring is different from lab PT testing. The policy changes outlined above are distinct from, and make no changes to, the PT clinical laboratory NCD.