Anticoagulation clinics

edited May 2017 in Primary Care
I wonder if anyone is willing to provide input regarding how they are handling "incident to" billing in an anticoagulation clinic. Let's assume the physician initiated the care, and a face to face visit with the anticoagulation clinic nurse is occurring in the same office suite where the billing physician is present. I am mostly interested in people's opinions of the content of the visit. Let's say the nurse gets a brief history about medication compliance and information about any dietary changes or bruising, There are no concerns in this regard. Then, the nurse examines the patient by checking a blood pressure and pulse and examines the skin. The exam is completely normal. Then, the INR (protime) is checked and it is within the target range. The patient is told to continue the same dose of the oral anticoagulant.

I am interested in whether people believe this documentation supports the submission of 99211. Then, if you say "no", would your mind change if the INR was out of range and the dose of the oral anticoagulant was changed?

Thanks, Rich Fairley, MD


  • Dr. Fairley,
    Our MAC, Novitas Solutions has an informational article which I have copied and pasted for you. They do not want providers to bill 99211 with a PT/INR unless there is a medication change. The cardiology practices I bill for do not charge a 99211 unless there is a medication change.
    Novitas Solutions Position on the Necessity of E/M Services Submitted as a Component Service of Anti-Coagulation Management
    Novitas Solutions continues to experience both questions and confusion regarding the billing of 99211, (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician); in addition to the laboratory blood draws for warfarin management.
    An E/M (evaluation and management) service (99211) would be allowable if it is determined that the patient's medication needs adjustment, the INR is not therapeutic, or if the patient has symptoms that need to be addressed.
    The billing of an E/M service in addition to obtaining the clinical specimen (phlebotomy or finger stick) is not medically reasonable and necessary if the following conditions are met:
    If the INR is within the therapeutic range, and
    the documentation does not support a need for adjustment of warfarin dosage, or
    the documentation does not support that the patient is symptomatic, or
    the documentation does not support the presence of a new medical co-morbidity or dietary change.
    Rather, information may be relayed to the beneficiary telephonically, and there is no need for a face-to-face E/M service.
    In this clinical setting, the medical necessity of a unique clinical service may be predicated upon the clinical circumstances of a previous visit, i.e., a significantly sub or supra-therapeutic INR necessitates quick follow-up. Use of a flow sheet and established protocol helps to provide both good patient care and documentation of medical necessity in these cases. Documentation of the services provided by the physician or nurse, discussion of symptoms, side effects, patient observations, etc. are considered supportive of the 99211 service.
    The American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy suggests that the INR be checked daily until the therapeutic range has been reached and sustained for two consecutive days, then 2 or 3 times weekly for 1 to 2 weeks, and then less often based on stability of results. Once the INR becomes stable, the frequency of testing can be reduced to intervals as long as 4 weeks. Novitas Solutions expects to see the educational component of anticoagulation management reflected in the use of 99211 in the early post-initiation visits, and less frequently as the stable target of anti-coagulation is reached. Two cited European studies make a strong case for Patient Self-Testing and Management, in which case, the patient education would be documented within the appropriate level of an established E/M service, where time/counseling service guidelines would apply.

    Sharon Trader, COC
    Coding Specialist
    Med-Fast Management Services
    2507 S. Cage Blvd.
    Pharr, TX 78577
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