Oncology & Hematology Coding Alert

Don't get stuck with the bill for your hematologist's in-office monitoring of Coumadin use -- instead, learn the Coumadin coding ropes. One surefire way is to follow these three key guidelines.

"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 ...) may be appropriate also.

Remember: Medicare doesn't consider 99363 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 ...)

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 on the Internet at www.cms.hhs.gov/CoverageGenInfo/downloads/manual200901.pdf.

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."