Coumadin Clinics

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Coumadin Clinics
Q&As to aid use of the anticoagulant management codes
Questions abound about how to use 99363 and99364, the anticoagulant management codes for patients
on blood-thinning warfarin (Coumadin) treatment. Here are answers to some "frequently asked
questions" about these codes.
Question: The American Medical Assoc. (AMA) says these codes are meant to replace the bilting of
992I1 with a prothrombin time test (856I0). But Medicare won't pay for 99363 and 99364, so cen we
continue using 99211for our Medicare patients?
Answer: You should be able to continue to bill for care of your Coumadin patients the same way you
always have, i.e. the protime lab test (if you do the tests in your office) or the blood draw (if you don't)
and, when documentation and medical necessity warrant, the 99211.
Point of confusion: a CMS comment in the 2007 Medicare physician fee schedule on codes
99363-99364 states "we believe these services are bundled into E/M services and have assigned a status
indicator of B to these codes." Physicians were unsure which E/M service the codes would be bundled
into - 99211, or maybe the initial E/M where the physician decided to perform anticoagulant therapy.
However, some CMS officials have commented that the agency still expects to see E/M codes billed for
additional education, counseling or medical decision-making with prothrombin time tests. That's
probably the most official word you'll get for now from CMS that it's okay to continue billing 99211
when appropriate with a prothrombin time test.
Important note: Don't bill99363 and99364 to Medicare and require the patient to sign an advance
beneficiary notice (ABN) for the service. An ABN is only appropriate in cases of medical necessity.
The ABN would not be appropriate in this case because Medicare has stated it always considers the
service to be bundled (so there never would be an appropriate time to bill for it and get paid).
Question: I want to start billing my private payers using 99363 and 99364, but I don't know how to
price them.
Answer: CMS included relative value units (RVUs) for the codes in its physician fee schedule relative
value file, available on the CMS Web site, which you can use to calculate non-Medicare fees with your
own conversion factor. The work RVU is the value set by the AMA's relative value update committee.
Question:
We send
our Coumadin patients out for blood draws and their prothrombin time lab work,
then m.anage their tlosage rsve.r tlte phone. Is therc anyrhin.q h'e can hill
for this?
Answer: This is one service thaf 99363 and 99364 werc designed to be able fo report. So fbr your
non-Medicare payers. go ahead and use 99363 and99364 for phone management of your Couniaclin
patients. F'or Medicare, unfortunately, yeru still have no way fo report this service - Meclicare consiclers
it bundled. Iflwhen Medicare decides to pay for these codes. you should be able to bill them for phone
management.
Question: Will Metlicure ever deckle
nt po7'.fbr unticoogul(utt tncuwgement?
Answer: Pliysicians are keeping their fingers crossed that Medicare will decide to cover 99363 and
99364. CMS has been in talks with physician groups to iron out its problems with the co<ies. Rumore4
to be at issue: CMS officials reportedly fear that physicians might bill both the anticoagulant
management codes and 99211 for the same services. They would like to safeguard against this. But it
wouldn't necessarily solve the problem if Medicare released new CCI edits bundling 99363 wtth9921l
because CCI edits only cover codes billed together for the sarne patient on the same day. The
anticoagulant codes encompass 90 days. So it would be rare tar these to be billed the same day as a
992t1.