In-Office Coumadin Coding Made Easy

Many coders make the wrong ICD-9-CM choice for in-office monitoring of Coumadin use, according to an article posted on Coding News. Read what the editor says will help you support medical necessity for warfarin therapy.

1. Put Proper Code to Periodic PT Test

“Physicians often use PT [prothrombin time] to assess patient response to the drug warfarin,” says Barb Miller, MT (ASCP) SH, with Nebraska Medical Center.

When patients on warfarin therapy come to your “Coumadin clinic” for periodic testing to assess their anticoagulation status, you should report 85610 Prothrombin time for the test.

Remember the modifier: Be sure to append modifier QW (CLIA waived test) to 85610 (and that you operate with a CLIA certificate of waiver).

If the nurse needs to evaluate new symptoms such as bruising or bleeding — something beyond the basic PT visit — 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. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services may be appropriate also.

Remember: Medicare doesn’t consider 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) and 99364 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; each subsequent 90 days of therapy (must include a minimum of 3 INR measurements) to be payable codes under the physician fee schedule.

2. Pull Out V58.61 for Diagnosis

“Patients may be on anticoagulation therapy for many reasons, but you should not report the underlying condition as the primary code for the PT test,” says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Do this: “If the reason for the PT test is to monitor the effectiveness of anticoagulation medication, the primary diagnosis code for the service should be V58.61 Longterm [current] use of anticoagulants,” Slagle says.

You may report the underlying reason for the warfarin therapy, such as a personal history of blood diseases (V12.3), as a secondary diagnosis.

For a complete list of payable diagnoses, see the Medicare National Coverage Determination (NCD) for PT.

3. Let Necessity Guide Frequency

Changes in the underlying medical condition or warfarin dosing determine the need for repeat PT tests, so CMS does not establish an across-the-board frequency limitation for this.

On the other hand: CMS states, “In a patient on stable warfarin therapy, it is ordinarily not necessary to repeat testing more than every two to three weeks.”

Source: Oncology Coding Alert.

Evaluation and Management – CEMC

18 Responses to “In-Office Coumadin Coding Made Easy”

  1. Barbara OConnor says:

    Code V58.61 is only acceptable as a secondary diagnosis, so do you bypass this rule when coding for patients who are having their anticoagulation monitored? We have had problems getting paid when V58.61 is used as a primary diagnosis code.

  2. Teresa Tate says:

    I have the same concern. According to ICD-9, V5861 is a secondary dx only. What about using V58.83 as the primary dx, V58.61 as the secondary dx and the underlying condition as the 3rd dx? Wouldn’t that be more in line with what ICD-9 expects?
    I have not had any issues with using V58.83 as the primary dx when coding for medication management…. even when it is not listed on the LCD/NCD list. I did notice that a couple of years ago, someone must have mentioned this to their medicare carrier, because Noridian ammended the LCD for ProThrombin to include V58.83. Shouldn’t they have done this across the board for all their LCD/ NCD’s that include medication management? Make sense to me.

  3. Jane Durham says:

    We put code V58.83 first then V58.61.

  4. Gail Osborn says:

    We list the V58.61 code first, then the underlying diagnosis code for why the patient is on Coumadin, if that’s all they’re being seen for; if they are being seen for at least (3) other diagnoses, then we list the V58.61 (only) in the 4th diagnosis position and link it to the 85610(QW); if only seen for 1-2 other diagnoses, then we list and link to the V58.61 but include the underlying diagnosis as well since there is room for it.

  5. Pat Scott says:

    I use the V58.83 and then V58.61, and if I know the reason for the therapy, I list that code first.

  6. Stephanie Schroeder says:

    Per ICD 9 guidelines, V58.61 is a secondary diagnosis, so listing it as primary, would not be following the guidelines. I suspect it is more approriate to code first the V58.83, then V58.61 as secondary.

  7. Susan Montford says:

    Per coding guidelines, V58.83 code is primary, then V68.61 is coded secondary, and any additional codes.

  8. Pat Scott says:

    Is anyone having any trouble getting paid if the V codes are first?

  9. Anne Karl says:

    Remember that the designation of a secondary code in the V code section is for inptatient encounters. How would you code an outpatient/physician office encounter for a normal pre-natal visit if V22.0-V22.1 could not be coded as primary?

  10. Cheryl Muckenfuss says:

    Yes, ICD-9 guidelines direct using V58.61 as a secondary diagnosis code, but for laboratory billing that is not followed. V58.61 should be listed as the dx with CPT 85610 when performed for monitoring for coumadin therapy. This is the reason the test is being done. Refer to the CMS Prothrombin Time NCD, beginning on page 45 of the July 2009 NCDs.

  11. jackie krueger says:

    Our Cardiology office does not do the draws for Coumadin management. Our Doctor ONLY reviews the results and calls the patient with his/her instructions. How do we bill Medicare for this? They will not pay on the codes 99363 and 99364. Also do I need to include copies of the INR’s as we do OP Reports? Thanks in advance for your help.

  12. Carol Fiorvanti says:

    Are Internal Medicine and Family Medicine two different specialties?
    Need ans ASAP

  13. Diane says:

    Some thoughts on this please?? For “lab” visits for 85610 to monitor Coumadin use, we use V58.61, then reason for Coumadin use as 2nd, such as having had a stroke or a pulm emblsm in the past (V12.54 or V12.51). We are having debates over this; some believe current stroke (434.91) or current pulm emblsm (415.19) codes should be used rather than hx codes, while others believe this w/b incorrect, as the pts are on Coumadin because they have had these things in the past & are trying to prevent them from reoccurring. Other input w/b appreciated, thanks!

  14. Deanna Gross says:

    This seems to be a common question. Through all the documentation, the ICD-9 Coding rules do specify to use V58.61 as a secondary only but the NCDs show this as an acceptable primary with no mention of having to be secondary. The LCD Policy for 85610 does specify in the covered diagnosis that the v58.83 should be primary with V58.61 secondary. I have been searching and have been unable to find clear defined rules pertaining to this in regards to labs.
    If anyone can offer clarification, it would be greatly appreciated.

  15. David Grant, MD says:

    Who writes these rules and lists of codes? Are they TRYING to make a confusing mess of them? A lot of people need coumadin anticoagulation, and whatever the reason, ANYONE on it ought to be monitored regularly. If Medicare wanted to make it easy and sensible, they’d have one code for running the test.
    I believe Vaclav Havel (first president of the Czech Republic, and a playwright) wrote a play in which bureaucrats require that all paperwork submitted to them be in a special language they invented, that nobody actually speaks.
    “The chains of misery binding man are made of red tape.”

  16. Sharon says:

    It is now 2014, and we still have the debate over which diagnosis should be primary for cpt 85610. Has anyone ever found a decisive answer?

  17. Heather says:

    We have oftentimes found how Medicare actually processes a claim to be wholly at odds with how we are instructed to code it. For example, your using V58.61 as a primary DX for a PT/INR…which is a perfectly viable reason for performing this test. The NCD even lists it so as a valid DX for this test. Our contractor, Palmetto, recently started a “smart edit” program that will tell us before they adjudicate the claim that the DX doesn’t meet the guidelines. We fought with their EDI department over this because, submitting the claim thru to bypass their “edits” ended with a paid claim, rather than a claim denied for medical necessity. I had them reviewing the NCD for this lab and stated if CMS didn’t want us using this as a valid primary DX for 85610, then they should’ve put an * beside these codes on the list and noted that they could only be used as secondary and so forth. But until that happened, they were halting our claims from being perfectly acceptable to the same NCD they were stopping them against and they needed to fix it. They did. They don’t stop anymore. **Now, does that go with ICD guidelines, don’t think so. But there is a lot of guidelines in both CPT and ICD that are coding guidelines but there are a whole new set of guidelines our payers used. My coding instructor was certain to point out the big ones where it’s a “this is how we teach you to code it” and “this is how your carriers (ie Medicare) will process it” kind of thing.

  18. Sidney kahana physicist says:

    I am longtime AFib sufferer and warfarin
    user with greatly mismanaged inr msnbcs.
    One day technician obtained successive
    values: 1.3, 1.7. 2.3 without comment.
    INR is a stupid international committee
    defined standard, apparently viewed by physicians as “safe” because it is logarithmic. Not so, involves an exponential;
    Better to have stuck with pt and exponential different for differing finger stick machines.
    I simply set my goal at inr=2 to minimize
    extraneous bleeding, into my precious brain for example.Found local reproducible
    hospital lab and over a rather short period of time determined 3 mg x6 + 1.5 mg
    Yielded precisely desired INR of 2 5 yrs later
    Same dosage led to1.9. Will adjust accordingly and recalibrate. Won’t discuss
    ridiculous exchange with finger stick manufacturers and their armies of
    both hopeful physicians and militaristic
    Nurse technicians.