Professional Disease Mangement Programs Designed
Physicians, Medical Groups and Clinics
Q: What HCPCS code can be used to bill for services and supplies related to home PT/INR monitoring?
A: Providers should bill Medicare using the following “G” codes that describe the service/product provided: GO248, GO249 and GO250. These are to be billed by the physician.
Q: What CPT code(s) can be used to bill for the related evaluation and management services?
A: When a doctor (or advance practice practitioner) provides evaluation and management (E&M) services to a patient in conjunction with home PT INR monitoring, the provider can use the appropriate E&M CPT code describing the level of care provided. The E&M code reported might be one of several codes, beginning with CPT code 99201 – 99215, depending on a patient's condition and the services provided.
Q: What diagnosis code(s) supports the medical necessity for home PT/INR monitoring?
A: Providers should use the ICD-9-CM diagnosis code that most accurately describes the patient’s condition. For example, Medicare covers home PT/INR monitoring for patients with a mechanical heart valve(s) that have been on anticoagulation therapy for three months.
Q: Do physicians’ offices need a CLIA certificate to provide home PT/INR monitoring services?
A: The home PT/INR monitoring coverage decision does not address CLIA certificates or other requirements that Medicare generally requires for laboratory tests. The physician does not need to obtain a CLIA certificate to provide services if the patient uses the equipment at home to perform the tests and reports the results to the physician (or IDTF). However, physician providers do need a CLIA certificate if they are performing prothrombin time tests in their office/facility.
Q: Can physicians’ offices mark-up home PT/INR monitoring supplies or services?
A: No Section 1842(n)(1) of the Social Security Act requires CMS to impose a payment limitation on certain diagnostic tests where the physician performing or supervising the test does not share a practice with the billing physician or other supplier. Such a test was formerly referred to as a “purchased diagnostic test”. This statutory provision was codified in 42 CFR § 414.50. This rule requires an “anti-markup” payment limitation for the technical component (TC) of a diagnostic test.
Q: What can providers do to facilitate payment for home PT/INR monitoring and related services?
A: To ensure appropriate reimbursement, claims should be coded to accurately and fully report the procedures performed and the patient's condition with the appropriate ICD-9 diagnosis code. Documentation in the patient records should accurately reflect the services provided to patients. If a question arises, the physician may need to prepare and send a letter of medical necessity to the insurer.
Two of the most common reasons that claims are denied are:
• ICD-9-CM code was not included on the claim form.
• The claim form was not completely filled out – some elements were missing.
Q: Does the physician need to see the patient face-to-face to bill “G0250 physician review; interpretation and patient management?”
A: No. Face-to-face service is not required. Physicians may consult with patients by telephone.
Q: What is considered “medically necessary” by Medicare?
A: The test should be necessary for diagnosing and treating the illness or condition of the patient. That means it should not be experimental or investigational, it should be safe, effective, and provided in an appropriate setting by qualified personnel. Any procedure that screens for asymptomatic conditions is not paid.
Q: What training is necessary for the physician and Non-physician personnel?
A: The physician must show evidence of proficiency in the performance and interpretation of each type of diagnostic procedure performed. The proficiency may be documented by certification in specific medical specialties or subspecialties or by criteria established by the Medicare carrier.
Any non-physician personnel used to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency
Q: What is needed to Order home PT/INR monitoring
A: All home PT/INR monitoring procedures performed must be specifically ordered in writing by the physician who is treating the patient (beneficiary), that is, the physician who is furnishing a consultation or treating a patient for a specific medical problem and who uses the results in the management of the patient's specific medical problem. (Non-physician practitioners may order tests as set forth in § 410.32(a)(3).) The order must specify the diagnosis or other basis for the testing.
Q: Will the finger stick be reimbursed also?
A: No, Medicare reimburses for venous samples but not finger sticks. If the patient having the in-house PT test is covered by Private Insurance, you may be able to bill CPT code 36416 (Collection of capillary blood specimen e.g., finger stick, heel, ear stick) for the finger stick. Check with the insurance company for more information
Q. Why Can’t physicians prescribe the Home testing for PT/INR for self-testing at home to NEW warfarin usage patients?
A. Physicians can prescribe a Home testing for PT/INR monitor for use at anytime. However, Medicare does not cover home testing devices or monitoring services during the first three months of anticoagulant therapy. The purpose of the three-month window is to ensure that patients who are new to anticoagulation therapy are appropriately monitored and that their PT/INR is stable. Since PT testing is appropriate during the first three, Medicare does cover and pay for medically necessary PT testing performed in physician offices and independent labs if the providers are qualified to perform such tests. Medicare also reimburses physicians for patient evaluation and management services. AHC's PATIENT SELF TESTING will waive the fees for the first three months for NEW warfarin patients so that they may benefit from the advantages of home monitoring.
Q. What are the out-of-pocket patient costs for home PT supplies and services?
A. All Medicare patients must pay an annual Part B deductible amount of $155 before Medicare will cover medical expenses. Patients are responsible to pay 20 percent of the Medicare approved amount after they meet the deductible; however, supplemental policies may cover the co-pay balance.
Private Insurance Coverage:
Q. Do private insurers reimburse (cover and pay) for PT home self-testing?
A. Many private insurers cover and pay for home PT testing devices and associated services. Private insurers generally negotiate with providers and pay for services according to contracted/negotiated rates. For more specific information regarding coverage or payment, contact a particular insurer directly.
Q. Are home PT testing devices available to veterans through the Veterans Administration (VA) hospital system?
A. The VA system is different from Medicare. VA hospitals and military hospitals purchase and pay for medical products and services and provide these items directly to their patients. Some VA medical centers provide patient self-testing options.
Q: Who is eligible for home PT testing?
A: There is clinical evidence that any patient requiring long-term anticoagulation may benefit from a home PT program. It is critical that the patient be capable of being trained to conduct a test and report the result to the caregiver. While physicians can elect to place any long-term patient on a home PT program, it is important to recognize that insurance carriers may be selective in whom they qualify as eligible.
Q: Who “manages” the dosage?
A: The equipment and supplies are provided by the physician through direct contracting arrangement with AHC's PATIENT SELF TESTING . AHC's PATIENT SELF TESTING will manage the provision of supplies, and collect and provide the results to the physician under supervision and direction of the physician. The physician interprets the results and adjust the medication dose. The physician need not speak directly with the patient, as long as the results are documented in the medical record.
Q: If a physician decides that a patient is eligible for a home PT testing program, can the physician simply give the patient a test meter and send the patient home?
A: No. Patient self-testing is regulated by the FDA. There are strict requirements for patient registration, training documentation and regular follow-ups. If a doctor selects a patient as a candidate, the best means to begin the process is to coordinate through AHC's PATIENT SELF TESTING. Also there is no financial incentive to do so. Section 1842(n)(1) of the Social Security Act requires CMS to impose a payment limitation on certain diagnostic tests where the physician performing or supervising the test does not share a practice with the billing physician or other supplier. Such a test was formerly referred to as a “purchased diagnostic test”. This statutory provision was codified in 42 CFR § 414.50. This rule requires an “anti-markup” payment limitation for the technical component (TC) of a diagnostic test.