Primary Care Coding Alert

Question: How should I code for Coumadin management when our physician does the evaluation and consult over the phone for dosage of Coumadin from Protime results?

Oregon Subscriber

Answer: Although third-party payers may cover telephone management, Medicare does not allow billing for the service. Because most patients who use blood-thinning medications, such as Coumadin, are Medicare patients, you probably cannot bill for your family physician's (FP) indirect evaluation. In fact, most E/M services that Medicare covers require face-to-face contact with the patient.

But private insurance companies may pay for the telephone consultation, in which case you should report 99371-99373 (Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists] ). Before filing these codes, check with the insurer about coverage.

By performing this service over the phone, your FP is probably trying to cut down on how much time he or she spends managing Coumadin patients. Although having the patient come into the office is more time-consuming, you may capture additional charges this way. When the provider speaks with the patient in the office regarding a change in the dosage (or to remain at the same dosage), the doctor should charge the appropriate-level office visit (99211-99215). If the FP signs off on the chart authorizing the nurse to relay the information to the patient, use 99211 (Office or other outpatient visit for the evaluation and management of an established patient typically, 5 minutes are spent performing or supervising these services).

For the tests to evaluate the patient's blood-clotting rate, report a finger stick or a prothrombin time (Protime) test based on payer and who performs the test. If your office collects the specimen and sends it to an outside lab for analysis, some private payers, but not Medicare, may allow 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]). On the other hand, you should report an in-office Protime test with 85610 (Prothrombin time) appended with modifier -QW (CLIA-waived test) to indicate that CMS includes the test on a list of procedures that do not have to meet the requirements of the Clinical Laboratory Improvements Amendments.