Wiki 99211 Anticoagulation managment


Findlay, OH
Best answers
Ok. Anyone... please give my some advice on this one.
In a physicians office with a Pharm D. doing anticoagulation management visits. Following all of the incident to guidelines. They want to bill a 99211 for every protime check. They do the PT/INR, BP check, ask them about their diet, any bruising or bleeding problems, change in medications, re educate them on rules while on the medication and then change the dose if necessary. Is it right to bill a 99211 for all of them?

Anyone have a setup like this outside of the hospital?

If a Medical Assistant or Nurse did all of that you would bill a 99211 so why not for a Pharm? Hey if the Dr. was doing it you could bill a 99213 at least.

If the pharmacist is providing this service look at MTMS (medication therapy management services) 99605-99607, based on time.
99363 and 99364 are not Medicare covered codes. And I know Medicare isn't covering the Pharm. D. Codes yet either. It would help greatly if they were!

Our concern is:


Can medical necessity really be met every time. I been hearing that Medicare is re couping their payments from practices doing this. Anyone else hear about this?
This has been a back and fourth issue with our practice and I can never seem to get anything definite. We were billing 99211 for our NP to do PT/INR test strips, dose change, discussion, etc. but I went to an AAPC seminar last year and the CPC said that it is NOT appropriate to bill 99211 for every visit. The more I have looked in to it, I think it would be appropriate to bill a 99211 in certain cases (as long as you have appropriate documentation) but you should be using the 99363-99364 coumadin management codes. We have been using these codes--you are right, they are non-covered bundled codes with Medicare. It's a huge pain but some insurances pay for them (except UHC for us). Good luck! I would love any additional advice people have to offer.
We have folks come in for their anticoagulation chk and there is a charge for 85610 and 36416 with the 99211. These are not done in the home. Where is the MLM that I can reference stating what requirements are to be met for this 99211. Tired of the argument that you cannot charge for the 99211 for every pt that comes in.

At a seminar given by a CMS consultant, she stated that Medicare does not expect to see 99211 at every visit. She stated that it should be used only when medically necessary, such as when there are new signs or symptoms reported by the patient or a change in medication dosage.

The consultant gave The National Government Services - Medicare Part B Bulletin September 2004 as her reference. She stated that if the patient has no new symptoms or does not require a dosage change, the physician cannot report 99211.
for the 99363 and 99364, you can bill these every 90 days and not a day shy of 90 for Medicare to pay. We have had no problems with Medicare paying for these codes. You bill the initial 90 after the visit where the Coumadin is first prescribed as long as you have a minimum of 8 PT/INR results, then 90 days after that you can bill the 99364 as long as you have 3 PT/INR results within that 90 days and so on. If the pt's coumadin is interrupted for inpt admit or surgery or for whatever reason the the entire process starts all over, you have the visit where the coumadin is restarted, then 90 days after that with 8 results on the chart you bill the 99363 and so on.

As far as the 99211, in 2002 on Feb11, Kathleen Mueller (compliance officer for CMS) wrote an article for Decision Health as a special report on the 99211. In this article she expressed that it is incorrect to charge a 99211 for blood draw encounters. Even if the nurse checks vital signs.
Mitchellde --what are your thoughts on this, my ortho doc wants to bill 99363 for our postop patients that are enrolled in home health, he is managing /adjusts PT INR for. Is this the appropriate code to be billing b/c the pt is not face to face.