Prothrombin Test/INR Monitoring

The Vascular Group that I code for is starting a "Coumadin Clinic." The patients will come every few weeks or so, and see a nurse for INR monitoring. Can someone please advise how to code for this service in an office setting. Also, any advice on documentation will be appreciated.
Thanks!
Paulette B Stone, RCC
Mountain Medical Physician Specialists
Murray, UT

Clinic

What exactly will the nurse be doing? There has to be a medically necessary reason for any encounter. Documentation must state an "action" was taken. A nurse visit is 99211. These clinics have been under surveillance due to questionable medical necessity encounters.

Clinic

CPT codes 99363 and 99364. For example, 99363 states "...outpatient taking warfarin, physician review and interpretation of INR testing, patient instructions, dosage adjustment, and ordering of additional test; initial 90 days of thereapy (must include a min of 8 INR measurements).
Some insurance carriers are reimbursing these codes. Medicare has these as “bundled” services.

Don't get me started!

We bill 99211 and the code for the protime. Diagnosis is V58.61 and the dx for the disease, such as 427.31. Our documentation includes vital signs, questioning on dosage, asking about bruising and bleeding, the test result and the doctor's decision on the next dose to take. This CLEARLY is Medical Decision Making. It is not the same as a BP check or drawing blood for a lipid panel and warrants a 99211 code. Be sure your doc signs every note and you clearly indicate "the results were discussed with the doctor and she recommends x mg daily and test next in x weeks."

coumadin monitoring

Some of us like to get signaturedoc started, because he is the most knowledgeable doctor we know.

Nancy had described the INR codes in the CPT book. These codes have a status indicator of B, Bundled. Search the database (that is, the articles in Codapedia) for 99363 and two articles come up, about these codes. The codes are bundled: that is, you don't receive any payment for them from Medicare or any insurances, and you can't bill the patient.

The standard of care I see is to bill these PTINR checks and medication adjustments as nurse visits. This assumes that you do the lab test (and bill for it) and the nurse has the results, adjusts or keeps the same the patient's coumadin dosage. The MA/RN documents a brief SOAP note: S: Patient returns for a coumadin check. No bleeding or bruising. No complaints. (or whatever the patient's complaints are, of course.) 0: vitals, INR results. A: Good or bad results. P: dosage. "Discussed with ...." or "Adjusted dose based on protocol XYZ".

Also, the nurse visits must meet the requirements of incident to services for Medicare. Look in Codapedia for incident to articles, and make sure you meet the requirements.

All over the country, these visits are billed as nurse visits, 99211.

Nancy is perfectly correct in saying that some payers question the medical necessity of the visits. Physicians, however, say they are absolutely necessary, that there is clinical evidence that supports the importance of close monitoring and frequent adjustments. I generally support billing these visits as nurse visits, incident to the physician services. People of good will and integrity, can disagree.