Primary Care Coding Alert

Illinois Subscriber

Answer: You should bill anticoagulation management of a Medicare beneficiary with protime code 85610 (Prothrombin time), plus E/M 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, instead of 99363. CMS considers 99363 Status B, or bundled, and thus not separately payable for Medicare.

Check with private payers on whether their policies allow using 99363 for overseeing a patient as an outpatient on a monthly basis with lab results. If a private payer covers 99363, you should not bill the code unless the physician supervises the Coumadin management directly.

If a nurse performs the management, you should bill 85610 and 99211, provided the nurse documents that the visit is more than just a "standard" Coumadin check in which she does only the prothrombin time. Code 99211 implies there was some evaluation and management of the patient. For example, the nurse should document other symptoms, such as bruising or bleeding, that needed more attention than a normal Coumadin check to report 99211 with 85610.

Code 85610 has no global period and therefore does not require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on 99211. Medicare carriers and many private payers, however, require modifier 25 on the E/M code for proper processing. Find out your major payers- policies.