Reimbursement Quick Reference Guide for Prothrombin …

1 PN 100299 Rev AA CoaguSense, Inc. Effective Date: 4/9/2010 Page: 1 of 2 DCO: 733 Reimbursement Quick Reference Guide for Prothrombin time /INR Testing Laboratory Services such as PT/INR testing performed in a physician s office are covered under Medicare Part B, if deemed reasonable and necessary for diagnosis or treatment of an illness. Medicare does require that the test be ordered by a licensed medical practitioner and be identified on the claim using a diagnosis or ICD-9-CM Code. CPT Codes are also required to identify medical tests and procedures.

2 CPT Code Description 2009 Payment 85610 Or 85610 (QW) Prothrombin time : Aid in screening for congenital deficiencies of Factor II, V, VII and, X; screen for deficiency of Prothrombin ; evaluate effects of heparin, Coumadin or warfarin; screen for Vitamin K deficiency. (QW is a modifier to signify CLIA Waived status) $ * (Standard National Average for PT/INR Test) * Reimbursement for each state can differ from the National Average. Fee information can be obtained through CMS website. Diagnosis Code Diagnosis Code Mechanical Heart Valve Atrial Fibrillation Deep Vein Thrombosis Atrial Flutter Pulmonary Emboli Mitral/Aortic Valve insufficiency Protein S deficiency Protein C deficiency TIA CVA Congestive heart disease Cardiomyopathy Hypercoagulable disorder Lupus Evaluation and management (E/M) Codes can be determined by the patient s condition and level of services rendered.

3 They can be all billed with the HCPCS G Codes, or the 85610/85610QW Code. E/M Code E&M of NEW Patients time spent face to face with patient and/or family Medicare Payment Rate* 99201 Problem focused history; Problem focused examination; Straightforward medical decision making; Self limiting, minor presenting problem. 10 minutes $ 99202 Expanded problem focused history; Expanded problem focused examination; Straightforward medical decision making; Low to moderate severity presenting problem. 20 minutes $ 99203 Detailed history; Detailed examination; Low complexity medical decision making; Moderate severity presenting problem.

4 30 minutes $ 99204 Comprehensive history; Comprehensive examination; Moderate complexity medical decision making; Moderate to high severity presenting problem. 45 minutes $ 99205 Comprehensive history; Comprehensive examination; High complexity medical decision making; Moderate to high severity presenting problem 60 minutes $ PN 100299 Rev AA CoaguSense, Inc. Effective Date: 4/9/2010 Page: 2 of 2 DCO: 733 E/M Code E&M of ESTABLISHED Patients time spent face to face with patient and/or family Medicare Payment Rate* 99211 May not require presence of a physician; Minimal presenting problems 5 minutes $ 99212 Problem focused history; Problem focused examination; Straightforward medical decision making; Self limiting, minor presenting problem.

5 10 minutes $ 99213 Expanded problem focused history; Expanded problem focused examination; Straightforward medical decision making; Low to moderate severity presenting 15 minutes $ 99214 Detailed history; Detailed examination; Moderate complexity medical decision making; Moderate to high severity presenting problem. 25 minutes $ 99215 Comprehensive history; Comprehensive examination; High complexity medical decision making; Moderate to high severity presenting problem 40 minutes $ CMS payment for physician-directed diagnostic benefit is as follows: HCPCS G Code Short Description Medicare Payment Rate* G0248 Demonstrates use of home INR monitoring $ G0249 Provide INR Test Material $ per 4 tests G0250 MD review/interpret/manage results $ per 4 tests * 2009 Medicare Physician Fee Schedule payment amounts effective January 1, 2009, geographic adjustments and local allowances can vary.

6 Additional Resources: ; Disclaimer: This Reimbursement Quick Reference Guide for PT/INR Monitoring is for information purposes only. No guarantee of payment is stated or implied and it is the responsibility of the health care provider to properly code and seek Reimbursement for necessary services rendered.