Cardiology Coding Alert

Hint: Watch the diagnosis -- you may be surprised by what you find.

Make sure you're not left with the bill for your cardiologist's in-office monitoring of Coumadin use by learning the Coumadin coding ropes. Ensure coding success by following these key guidelines.

Depend on Modifier for Periodic PT Test

When patients on warfarin come to your "Coumadin clinic" for periodic testing to assess their anticoagulation status, you'll report 85610 (Prothrombin time) if your practice performs the lab service.

"When the patient is on Coumadin we routinely check PT (Prothrombin time) and INR (International Normalized Ratio). We do this in our office with a 'finger stick,' and we code this service with 85610," says Jennifer Crowell, CPC, CCC, CEMC, lead hospital coordinator and lead coder at Spokane Cardiology in Washington. "The PT evaluates the ability of blood to clot properly while the INR is used to monitor the effectiveness of blood thinning drugs such as warfarin (Coumadin)."

Modifier tip: Be sure to append modifier QW (CLIA waived test) to 85610 -- and that you operate with a CLIA certificate of waiver. "QW is always used on lab codes that are CLIA exempt," says Sandy Fuller, CPC, MCS-P, HIS supervisor and compliance officer at Cardiovascular Associates of East Texas in Tyler. CLIA waived status is a certification that is required for your practice to perform PT/INR testing.

Note: Medicare doesn't consider 99363-99364 (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 ...) payable under the physician fee schedule. You should report 85610 instead, assuming you perform the lab test. CMS considers 99363 and 99364 to be status "B," or bundled, and therefore not separately payable by Medicare.

Check with your private payers to see if their policies allow you to use 99363-99364 for overseeing a patient as an outpatient on a monthly basis with lab results. If a private payer covers 99363-99364, you should not bill the code unless your physician supervises the Coumadin management directly.Prove Medical Necessity Before Adding 99211 If new symptoms beyond the basic PT visit need to be evaluated, such as bruising or bleeding, 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...) may be appropriate also.

Warning: Be sure that you have documentation to back up that you actually did perform the 99211 and why you performed it. "We bill for the nurse visit many times," says Crowell. "Noridian allows this and in fact just sent out 'clarification' for incident to/nurse visits. In the Noridian document they list specific examples where you may bill a nurse visit." For more on Noridian's 99211 policy, visit www.noridianmedicare.com/provider/updates/docs/incident_to_billing_99211_acro.pdf.

Similarly, according to WPS Medicare, "Services billed to Medicare under CPT 99211 must be reasonable and necessary for the diagnosis and treatment of an illness or injury.

Furthermore, a face-to-face encounter with a patient consisting of elements of both evaluation and management is required. The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient. The management portion is substantiated when the record demonstrates an influence on patient care."

Don't separately report 99211 and the PT test in the following circumstances for example:

• When documentation of the presenting problem and medical evaluation does not support a separate E/M service on the same date
• When there's no documentation of a face-to-face E/M service -- such as phone calls with patients.

For more on the WPS policy, visit www.wpsmedicare.com/j5macpartb/departments/cert/certfocus99211.shtml.

Save Underlying Condition for Secondary Dx You may be tempted to report the patient's underlying condition as your diagnosis code, but watch out. You should not use the underlying condition as the primary code for the PT test.

Tip: If the reason for the PT test is to monitor the anticoagulation medication's effectiveness, look to V58.83 (Encounter for therapeutic drug monitoring) as your primary diagnosis. ICD-9 instructs you to "use additional code for any associated long-term (current) drug use," and in the case of Coumadin, you should report V58.61 (Long-term [current] use of anticoagulants).

You may report the underlying reason for the warfarin therapy as a secondary diagnosis.

"These anti-coagulant drugs help inhibit the formation of blood clots. They are prescribed on a long-term basis to patients who have experienced recurrent inappropriate blood clotting. This includes those who have had heart attacks, strokes, and deep vein thrombosis (DVT)," Crowell says.

Bottom line: So multiple diagnosis codes could apply to your PT test claims, depending on the reason your physician prescribes the warfarin. For example, "Our most common diagnosis codes for this are 427.31-427.32 for atrial fibrillation and atrial flutter, V43.3 and V42.2 for S/P heart valve surgeries, 790.92 for abnormal coagulation profile, and 415.19 for pulmonary embolism," Crowell says. "Then sometimes we will need signs or symptoms like bruising, bleeding, or anything else you might gather during a nurse visit." Another possibility is V12.51 (Personal history of venous  thrombosis and embolism).

For a complete list of payable diagnoses, see Medicare's lab National Coverage Determination (NCD) Manual document at www.cms.hhs.gov/CoverageGenInfo/downloads/manual201001.pdf.

Let Necessity Determine Frequency

Since the need for repeat PT tests is determined by changes in the underlying medical condition or warfarin dosing, CMS does not place any frequency limitations on testing.

Exception: CMS states in the policy cited above, for "a patient on stable warfarin therapy, it is ordinarily not necessary to repeat testing more than every two to three weeks."