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Thread: PT Cost

  1. #1

    Default PT Cost

    AAPC: Back to School
    One of the clinics I work for does numerous prothrombin times (85610). I noticed when billing the PTs medical only reimburses about $5.74. Each PT test done costs $10.81 in actual materials, not including the nurses, insurance clerks, and my costs. I know you can't bill a 99211 just for a diagnostic visit. Is there anything else we can do to help cover this cost. It is an important procedure for our patients, but one the office will not continue if they are losing money on it. What other options are available to the clinic?

  2. #2


    Does anyone know what options we have or will be most cost effective one be to outsource our PT tests?

  3. #3
    Join Date
    Apr 2007
    Columbia, MO


    G0001 (Medicare code for venipuncture) is being deleted and replaced with 36415, effective Jan. 1st. The service will continue to be payable under the lab fee schedule. Carriers will be able to pay correctly for the use of 36415 for venipuncture by Jan. 1 when the new fee schedules take effect, according to CMS. Medicare used to cover venipuncture with code 36415, but implemented the G code because 36415 included collection of blood through the finger, heel or ear stick - all services not covered by the program.

    But a distinct CPT code, 36416, was created in 2003 to bill for the parts of the venipuncture service not covered by Medicare. That code will remain non-covered, CMS says. The agency is making a late switch back to 36415 because the definition of the code now matches the definition of G0001, a CMS official says. Routine venipuncture with 36415 is a "simple" blood draw that does not require the physician's skill. Remember, you shouldn't bill for a 99211 ($21.28, par, national, office) unless you have a medically necessary reason other than the venipuncture.
    The above is actually from BCBS,
    From Trailblazers:
    Among other things, code 99211 should not be used to bill Medicare:
    • For phone calls to patients.
    • Solely for the writing of prescriptions (new or refill) when no other E/M is necessary or performed.
    • For blood pressure checks when the information obtained does not lead to management of a condition or illness.
    • When drawing blood for laboratory analysis or when performing other diagnostic tests, whether or not a claim for the venipuncture or other diagnostic study test is submitted separately.
    • Routinely when administering medications, whether or not an injection (or infusion) code is submitted on the claim separately.
    • For performing diagnostic or therapeutic procedures (especially when the procedure is otherwise usually not covered/not reimbursed or payment is bundled with payment for another service), whether or not the procedure code is submitted on the claim separately.
    And there are more but the long and short of it all is that you may not bill a 99211 for a blood draw encounter regardless of vital signs taken.

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