There are a few remarkable things about coding for anticoagulation management services.

First, payment for these services bolsters Medicare’s support for primary care. This monitoring is typically done by either primary care or cardiology and was considered part of the pre-and post-work for an office visit. Although there were CPT^® codes for anticoagulation management prior to 2018, when these codes were valued, they had a status indicator of bundle and were not reimbursed by any payers.

Second, although the payment is low particularly for the management in response to the INR test, some practices perform this service frequently. It is payment for management work that is already being done.

Currently, there are two sets of codes, two CPT^® codes and three HCPCS codes. They aren’t defined consistently and and this article explains the differences.  The HCPCS codes relate only to home INR monitoring, while one of the CPT^® codes can be used when the test is done in the home, office, or lab.

Home INR testing, and management of home INR test results

93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient’s/caregiver’s ability to perform testing and report results

93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed

93793 may not be reported on the same day as an office/outpatient visit or outpatient consultation, per CPT.

93792 is for patient/caregiver education for initiation of home international normalized ratio (INR) testing. The patient obtains the equipment from a DME provider (“the provision of test supplies and materials is reported separately with code 99070, Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided), or the appropriate supply code.)[1] to test their own blood at home, and prior to doing the testing, a staff member has a face-to-face educational session with the patient, showing them how to collect the sample and test their blood, and documenting their ability to perform the tests and report the results. 99070 has a status indicator of bundled. Medical practices are not paid for providing supplies to patients. 99792 was assigned zero wRVUs, because it is staff work only, possessing total RVUs and an associated payment.

93793 is for a non-face-to-face review of INR results and management. It is payment for reviewing the results of an INR done at home, at the office, or in a lab.

Now, to the older, HCPCS codes that relate only to home INR services.

HCPCS codes, G0248, G0249, G0250

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

 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; not occurring more frequently than once a week

 G0250: Physician review, interpretation, and patient management of home INR testing for a patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes face-to-face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring; not occurring more frequently than once a week

These three codes are longstanding codes with a status indicator in the Medicare fee schedule of R, restricted. These are Contractor priced, although there are RVUs in the fee schedule. They were not deleted with the addition of the CPT^® codes.

G0248 is similar to CPT^® code 93972. Both require in-person education, obtaining one sample, instructions for reporting, and an assessment of how well the patient will be able to perform the test and report the results.

G0249 includes providing the machine and materials for INR testing. This is not a DME benefit but is paid under the physician fee schedule. The practice provides the machine that the patient uses to test their blood.

G0250 requires “face-to-face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring.” The frequency of the face-to-face verification is not listed in the code.

G0250 and 93793 are similar but with a key difference:

The difference is where the lab test was done.  Use of code G0250 is not more than once a week, and is only used for home testing of INR. 93793 is used for review and management of a new test done at home, in the office or in the lab. 93793 specifically requires providing patient instructions, dosage adjustment, if needed, and scheduling additional tests, when needed. 93793 is used in more situations. It allows billing non-face-to-face assessment and management of INR tests done at home, in the office or at a lab, but it also has more specific requirements for patient instructions and management.

If your practice has been reporting these HCPCS codes, compare the descriptions of the HCPCS codes and CPT^® codes carefully, and the payment from your Contractor. For non-Medicare patients, use the CPT^® codes. You can read more about the requirements for the HCPCS codes in Chapter 32 of the Medicare Claims Processing Manual.

Nurse visits and INR

G0248, 93792 both describe for teaching the patient how to do a home INR providing the INR machine and materials (G0249), and monitoring and dosage adjustment based on the patient’s results. (G0250–home, 93793—home, office, lab)

But not all patients want to or can test their own blood at home. Some patients have the test done at their doctor’s office, and these do not always fall on the day of an office visit. If the patient has the service done on the same day as an office visit, bill the office visit done by the physician/NP/PA and bill the PTINR, 85610. For CLIA-waived tests, add modifier QW (must be submitted in the first modifier field.)[2]. The CPT^® code for a fingerstick, 36416, has a status indicator of bundled, and Medicare won’t pay it, and neither will most payers. Do not bill either a nurse visit (99211) or 93793 when done on the day of an office visit.

If a patient presents to have her PTINR checked, the lab test is performed and the nurse provides the management advice about the dosage of Warfarin that may be billed as a nurse visit (99211), in addition to the lab test. The nurse must provide the treatment advice face-to-face with the patient, either in consultation with the physician/NP/PA or based on a scale developed by the practitioner. Remember if it is a Medicare patient, you must meet incident to guidelines.

Nurse visit or 93793?
That depends on whether the work is done in-person or not. Again, neither 93793 or a nurse visit may be performed on the day of another E/M service.

Frequently Asked Questions | Coding for Anticoagulation Management

Can these be performed on the same day as an E/M service?

CPT^® says that a separately identifiable E/M service may be reported on the same day as 93792, instructions and training for a patient who will start home INR monitoring.

CPT^® says “Do not report 93793 on the same day as an E/M service.”

So, if the INR is done on the day of the visit and the physician/NP/PA interprets the result and gives the patient dosage instructions, do not report 93793 in addition to the E/M.

CPT^® also states not to report either code during the service time of chronic care management (CCM) or transitional care management (TCM). (99487, 99489, 99490, 99495, 99496)  During the service period would mean during any calendar month of reporting CCM and during the 30-day post discharge period if billing TCM.

This is good news.  It is payment for services medical groups are already doing.

Can we bill for RN services?

Question:

My question is regarding Anticoagulation Management Code 93793. Guidelines state that this code can be performed by a physician, NP, or PA. My question is, if clinical staff performs the service in the doctor’s office setting, can code 93793 be billed under the supervising physician’s name?

Clinical staff:

• Sees the patient face to face
• Queries the patient regarding any unexplained bleeding, bruising, changes in diet, any other interacting medication usage, etc.,
• Obtains the PT INR
• Reviews the results
• Changes dose or keeps the same dose according to an AMS flowsheet
• Arranges future appointments
• Clinical staff then routes the note to the physician for review, any documentation changes and final sign-off

Can this code be billed under the physician’s name when performed by clinical staff in the doctor’s office setting? If so, would there have to be an attestation and/or co-signature by the physician?

Answer:

This code does not require a face-to-face service, but there is nothing in the description that precludes it being performed at least partially face-to-face (however, 99211 might better fit the scenario, as outlined above) It may not be done on the day of an E/M service and be sure to check the CPT^® book for other “do not report” with codes, which include chronic care management and TCM.

In my opinion, part of the work could be done by the clinical staff. Ultimately, the management of the Warfarin must be a medical decision. I think an update and then sign-off could work as a process. The 2018 CPT Assistant states that the 93793 covers:

• ordering, reviewing, interpreting new INR test result(s),
• providing patient instructions, and
• making dosage adjustments, as needed.

As long as the above is documented in the “care plan” or the reason in a prior E/M service documenting the ideal INR parameters, the service could be done by staff; however, if the parameters were breached, MD intervention might be required.

[1] CPT® Assistant, March 2018; Volume 28: Issue 3: International Normalized Ratio (INR) Monitoring Services (93792, 93793)

[2] https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00099344

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