Practice Management Alert

Revert to former billing options to get paid

Question: My doctor has asked me to look for the new Coumadin codes and instructions on how we should bill them. Can you tell me how to bill these types of services and how much we can expect to get paid by Medicare and private carriers?

Unfortunately, you shouldn't expect payment on the new Coumadin codes, but there is hope for payment.

Hopes raised: On Jan. 1, CPT 2007 introduced two new codes to report outpatient management of warfarin sodium (an anticoagulant also known as Coumadin), and billers hoped this would lead to proper payment for this service. The two new codes are:

- 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).

Hopes dashed: Originally, CMS seemed poised to pay $100 for 99363 and $35 for 99364. However, CMS made both codes Status B, or bundled, and thus non-covered for Medicare.

Solution: If you have an in-house lab, you should keep using protime code 85610 (Prothrombin time), plus evaluation and management 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 ...) 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.

If the visit doesn't meet the criteria for billing the 99211 E/M service, you should report 36415 (Collection of venous blood by venipuncture) for the blood draw. If you don't have an in-house lab, you-ll just report the blood draw or E/M service code, and the lab will bill 85610.

Caution: You can't bill for 99363-99364 even if a payer 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. Again, this is only if you have an in-house lab.

Remember: 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.