Cardiology Coding Alert

Remember: Physicians should only bill G0250 once every four weeks.

The MAC Novitas recently clarified how to correctly report home prothrombin time/international normalized ratio(PT/INR) monitoring code G0250. A major mistake physicians make with this code is billing it too soon, according to Novitas.

Safeguard your G0250 (Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests) reimbursement with five handy tips.

Tip 1: Identify Differences Between G0248, G0249, and G0250

Make sure you know when you should report G0248, G0249, and G0250.

• If the physician demonstrates the use and care of an INR monitor, report G0248 (Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient’s ability to perform testing and report results).

Caution: You can report G0248 only once in a patient’s lifetime.

• For home INR monitoring supplies, report G0249 (Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests).

Caution: You cannot bill G0249 more frequently than once every four weeks.

• For the physician’s review of home INR testing, report G0250.

Caution: You cannot bill G0250 more frequently than once every four weeks.

Qualified personnel of the physician may obtain test results from the patient, but the physician must review and interpret the results, according to Ray Cathey, PA, FAAPA, MHS, MHA, CCS-P, CMSCS, CHCI, CHCC, president of Medical Management Dimensions in Stockton, California.

“These test results must be documented in the patient record,” Cathey says. “It is recommended that the physician acknowledge his/her review of all test results thus documented.”

Tip 2: Bill G0250 Just Once Every 4 Weeks

Medicare often denies claims for G0250 because the physician bills the code too soon. Physicians should only bill G0250 once every four weeks (28 days). If the physician submits G0250 before the 28 full days have passed, Medicare will deny your claim.

Many physicians want their patients to perform the test more frequently than once per week when the test result isn’t optimal (too high or low), according to Cathey.

“The provider then wants to bill for more than four tests, because the understanding is that the G0250 is ‘per four tests,’ but they don’t understand the caveat that the test is once per week, so after completing four tests in two weeks, the provider bills G0250 and adjusts the warfarin dosage,” Cathey says. “Then after four more tests in two weeks, the provider again bills G0250.”

While the frequency of the testing is not disputed, the code states ‘… not occurring more frequently than once a week,’ according to Cathey.

Medicare doesn’t dispute the necessity for more frequent testing. But the code description and Medicare’s policy indicate that CMS won’t approve more than four tests per 28 days, so billing should not occur sooner than 29 days apart, Cathey says.

Meeting the time restriction for G0250 is essential, but how can you make sure you’re on the right track? “Since Medicare has specific timing parameters for the coverage of HCPSC code G0250, the frequency limitation information should be shared with the practitioners and billing staff to assist in operational billing and reimbursement processes,” says Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska.

“Consider incorporating flags/edits in the billing software for G0250 to help ensure 28 full days have passed (not occurring more than once a week, billing units of service include four weeks), to avoid claim denials,” Swanson suggests.

Swanson also recommends that practices implement an internal policy and procedure for reporting G0250 outlining Medicare’s coverage, billing, and reimbursement policy.

Tip 3: Only Report G0250 for These Patients

According to MLN® Matters MM6313 Change Request (CR) 6313, Medicare covers the use of PT/INR monitoring for chronic, oral anticoagulation management for patients on warfarin with the following:

• Mechanical heart valves
• Chronic atrial fibrillation
• Venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism).

Medication definition: Warfarin (also known by the brand name Coumadin®) is an anticoagulant that reduces the formation of blood clots. Harmful blood clots can cause heart attacks, strokes, deep vein thrombosis, or pulmonary embolisms.

Testing definition: The prothrombin time (PT) test, a blood test that measures how long it takes blood to clot, and the INR, the calculation based on the results of the PT test, are the standard for evaluating the therapeutic effectiveness of warfarin therapy, according to MLN® Matters MM6313.

Tip 4: Remember G0250 Coverage Requirements

To correctly bill for G0250, a treating physician must prescribe the home testing, and all of the following criteria must be met, according to MLN® Matters MM6313:

• The patient must have been anticoagulated at least three months before using the home INR device.
• The patient must participate in a face-to-face antico­agulation management educational program, and he must demonstrate that he knows how to correctly use the device before using it in his home.
• Following the initiation of home monitoring, the patient must continue to correctly use the device to manage his anticoagulation therapy.
• The patient should not use the device for self-testing more than once a week.

Important: Patients with tissue valve replacements (such as “porcine” valves) are not part of the NCD, so Medicare will not make payment on home INR monitoring for patients with porcine valves unless covered by local Medicare contractors, according to Cathey.

Tip 5: Double-Check Your Documentation

Documentation for G0250 should include the following elements, Cathey says:

• Date of test
• The diagnosis
• The target INR range
• The patient test result.

Physicians should include medical record documentation to support the medical necessity of G0250 by listing all of the applicable patient’s diagnoses, Swanson adds.

“Medicare will cover the use of PT/INR monitoring for patients on warfarin with mechanical heart valves, chronic atrial fibrillation, and venous thromboembolism,” Swanson says. “When a practitioner prescribes and bills G0250, additionally, medical record documentation should support the physician’s order, test results, review, interpretation, and patient management of home INR testing for patients with these medical conditions.”

Physicians should also include the details supporting that the patient meets the mandatory requirements for G0250, as outlined in Tip 4, according to Swanson.

Be sure to document a statement that the test results were obtained and the interpretation communicated to the patient or their representative and that any medication changes were made in conjunction with the provider, per office protocol and approved by the provider, Cathey reminds.

“I would also suggest that the statement includes a comment such as ‘the patient (or representative) appears to understand’ the new instructions,” Cathey says. “And the physician review/signature is required.”