Reimbursement

Professional Market
Payment for Prothrombin time testing is fully reimbursed in the professional setting. Potential reimbursement for the professional market was derived from the Medicare fee schedule as follows:

• PT/INR test:
  Code 85610 Clinical Lab Fee Schedule
• Blood draw:
  Code G0001 Part B Extract and Surveillance System
• Office visit:
  Code 99211 (for lowest level) RBRVS Fee Schedule

Patient Self-Testing Market
Payment for services furnished on or after July 1, 2002, Medicare will cover the use of home prothrombin time INR monitoring for anticoagulation management for patients with mechanical heart valves on warfarin. The monitor and the home testing must be prescribed by a physician and the following patient requirements must be met:

• Must have been anticoagulated for at least three months prior to use of the home INR device;
• Must undergo an educational program on anticoagulation management and the use of the device prior to its use in the home; and
• Self testing reimbursement with the device is limited to a frequency of once per week.

Applicable HCPCS Codes

(Healthcare Common Procedural Coding System) These are medical codes that identify health care procedures, equipment, and supplies for claim submission purposes.

Reimbursement and payment for patients testing at home was recently approved by the Centers for Medicare and Medicaid Services (CMS), formally the Health Care Financing Administration, for Medicare patients on Mechanical Heart Valves. New HCPCS codes were created for submission and payment for (1) Patient Training (G0248), (2) Meters and Strips (G0249) and (3) Physician Review (G0250). The following are the complete descriptions of these new codes:

G0248:
Demonstration, at initial use, of home INR monitoring for patient with mechanical heart valve(s) who meets Medicare coverage criteria, under the direction of a physician; includes: demonstration 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 a patient ability to perform testing.

G0249:
Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meets Medicare coverage criteria. Includes provision of materials for use in the home and reporting of test results to physician; per 4 tests.

G0250:
Physician review; interpretation and patient management of home INR testing for a patient with mechanical heart valve(s) who meets other coverage criteria; per 4 tests (does not require face-to-face service).

For more information on reimbursement please contact us at: (800) 563-5680 toll free