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I know that some here are on home testing but for those who are not:
In March 2008 medicare added new criteria for home testing and I am sure this sets the pace and tone for most/many nationwide insurance companies. I could have been doing this at home for awhile and it would have been covered. I encourage all who can... to try and do same . Although it adds revenue to the doctors and clinics who do the testing, it costs far less( for all) to do it at home. NOT to mention the personal INCONVENIENCE, cost and time wasted going to the clinic each time you have to adjust / or check the INR for coumadin dose.
Here is the fact sheet:
Prothrombin Time (PT/INR) Monitoring for Home Anticoagulation Management
Reference: Trans. 1562 and 90, CR #6138, Pub. 100-04 and 100-03, MLN: MM6138
Published Online: 7/31/2008
Provider Types Affected
Physicians, providers and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FIs) or Part A/B Medicare Administrative Contractors (A/B MACs)) for home PT and International Normalized Ratio (INR) anticoagulation management monitoring services provided to Medicare beneficiaries.
Impact on Providers
This article is based on Change Request (CR) 6138, and alerts providers that effective for claims with dates of service on and after March 19, 2008 the Centers for Medicare & Medicaid Services (CMS) revised its National Coverage Determination (NCD) limits and will expand the population eligible for home coverage of PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin. See the Key Points section of this article for details.
Background
The prothrombin time (PT) test is an in-vitro test to assess coagulation. PT testing and its normalized correlate, the International Normalized Ratio (INR), are the standard measurements for therapeutic effectiveness of warfarin therapy. Warfarin, Coumadin®, and others, are self-administered, oral anticoagulant, or blood thinner, medications that affect a person’s Vitamin K-dependent clotting factors.
Currently, Medicare’s national coverage determination (NCD) at 190.11 of the NCD Manual limits coverage of home PT/INR monitoring to anticoagulation management for patients with mechanical heart valves who are on warfarin. The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a) (See http://www.cms.hhs.gov/ClinicalLabFe...ads/410_32.pdf on the CMS website.) and the following requirements must be met:
The patient must have been anticoagulated for at least 3 months prior to use of the home INR device;
The patient must undergo an educational program on anticoagulation management and the use of the device prior to its use in the home; and
Self-testing with the device should not occur more frequently than once a week.
CMS received a formal, complete, written request for reconsideration to expand the population eligible for coverage of home PT/INR monitoring to patients on warfarin. CR6138 is a result of that request.
Key Points of CR6138
Effective for claims with dates of service on and after March 19, 2008, CMS revised its NCD to provide for home coverage of PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin.
The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a) and all of the following requirements must be met:
The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and,
The patient must undergo a face-to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to its use in the home; and,
The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and,
Self-testing with the device should not occur more frequently than once a week.
Note: Applicable HCPCS Codes G0248, G0249, and G0250 will continue to be used for claims processing purposes for PT/INR. With the July 2008 Outpatient Code Editor (OCE) and Medicare Physician Fee Schedule updates, the descriptors of these codes will change to reflect the revised coverage policy
The following revised descriptors reflect the expanded NCD criteria and are effective for services on or after March 19, 2008 as follows:
Long Descriptor G0248: Demonstration, prior to initial use, of home INR monitoring for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of 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 patient ability to perform testing prior to its use.
Short Descriptor G0248: Demonstrate use home INR mon
Long Descriptor G0249: Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; not occurring more frequently than once a week
Short Descriptor G0249: Provide INR test mater/equipm
Long Descriptor G0250: Physician review, interpretation, and patient management of home INR testing for a patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes face-to-face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring; not occurring more frequently than once a week.
Short Descriptor G0250: MD INR test revie inter mgmt
Note: Test materials continue to include 4 tests. Frequency of reporting requirements shall remain the same.
Note: Porcine valves are not included in this NCD, so Medicare will not make payment on Home INR Monitoring for patients with porcine valves unless covered by local Medicare contractors.
Note: This NCD is distinct from, and makes no changes to, the PT clinical laboratory NCD at section 190.17, of the NCD Manual.
The following are applicable diagnosis codes to be used when submitting claims to Medicare contractors:
For services furnished on or after March 19, 2008, the applicable ICD-9-CM diagnosis codes for this benefit are:
V43.3 (organ or tissue replaced by other means; heart valve);
289.81 (primary hypercoagulable state);
451.0-451.9 (phlebitis & thrombophlebitis);
453.0-453.3 (other venous embolism & thrombosis);
415.11-415.19 (pulmonary embolism & infarction); or
427.31 (atrial fibrillation (established) (paroxysmal))
Medicare contractors will deny claims for PT/INR monitoring services that are not delivered in accordance with CR6138. Denied claims are subject to appeal. When denying such claims, your Medicare carrier, FI or A/B MAC will use the following codes:
Remittance Advice Remark Code N386, "This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp on the CMS website. If you do not have Web access, you may contact the contractor to request a copy of the NCD."
Claim Adjustment Reason Code 50 will be used: "These are non-covered services because this is not deemed a ‘medical necessity’ by the payer."
Providers should be aware that your Medicare Contractor will assign liability for the denied charges to you unless documentation of an Advance Beneficiary Notice (ABN) is present on the claim. Also, your contractor will not search for claims but will adjust inappropriately denied claims with dates of service March 19, 2008, through the implementation date of CR6138, that are brought to their attention.
Additional Information
CR6138 was issued in two transmittals, i.e., one for the NCD Manual and one for the Medicare Claims Processing Manual. These transmittals are available at http://www.cms.hhs.gov/Transmittals/...ads/R90NCD.pdf and http://www.cms.hhs.gov/Transmittals/...ds/R1562CP.pdf, respectively, on the CMS website.
If you have questions, please contact your Medicare A/B MAC, FI or carrier at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/d...mDirectory.zip on the CMS website.
Effective Date: March 19, 2008; Implementation Date: August 25, 2008
In March 2008 medicare added new criteria for home testing and I am sure this sets the pace and tone for most/many nationwide insurance companies. I could have been doing this at home for awhile and it would have been covered. I encourage all who can... to try and do same . Although it adds revenue to the doctors and clinics who do the testing, it costs far less( for all) to do it at home. NOT to mention the personal INCONVENIENCE, cost and time wasted going to the clinic each time you have to adjust / or check the INR for coumadin dose.
Here is the fact sheet:
Prothrombin Time (PT/INR) Monitoring for Home Anticoagulation Management
Reference: Trans. 1562 and 90, CR #6138, Pub. 100-04 and 100-03, MLN: MM6138
Published Online: 7/31/2008
Provider Types Affected
Physicians, providers and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FIs) or Part A/B Medicare Administrative Contractors (A/B MACs)) for home PT and International Normalized Ratio (INR) anticoagulation management monitoring services provided to Medicare beneficiaries.
Impact on Providers
This article is based on Change Request (CR) 6138, and alerts providers that effective for claims with dates of service on and after March 19, 2008 the Centers for Medicare & Medicaid Services (CMS) revised its National Coverage Determination (NCD) limits and will expand the population eligible for home coverage of PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin. See the Key Points section of this article for details.
Background
The prothrombin time (PT) test is an in-vitro test to assess coagulation. PT testing and its normalized correlate, the International Normalized Ratio (INR), are the standard measurements for therapeutic effectiveness of warfarin therapy. Warfarin, Coumadin®, and others, are self-administered, oral anticoagulant, or blood thinner, medications that affect a person’s Vitamin K-dependent clotting factors.
Currently, Medicare’s national coverage determination (NCD) at 190.11 of the NCD Manual limits coverage of home PT/INR monitoring to anticoagulation management for patients with mechanical heart valves who are on warfarin. The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a) (See http://www.cms.hhs.gov/ClinicalLabFe...ads/410_32.pdf on the CMS website.) and the following requirements must be met:
The patient must have been anticoagulated for at least 3 months prior to use of the home INR device;
The patient must undergo an educational program on anticoagulation management and the use of the device prior to its use in the home; and
Self-testing with the device should not occur more frequently than once a week.
CMS received a formal, complete, written request for reconsideration to expand the population eligible for coverage of home PT/INR monitoring to patients on warfarin. CR6138 is a result of that request.
Key Points of CR6138
Effective for claims with dates of service on and after March 19, 2008, CMS revised its NCD to provide for home coverage of PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin.
The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a) and all of the following requirements must be met:
The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and,
The patient must undergo a face-to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to its use in the home; and,
The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and,
Self-testing with the device should not occur more frequently than once a week.
Note: Applicable HCPCS Codes G0248, G0249, and G0250 will continue to be used for claims processing purposes for PT/INR. With the July 2008 Outpatient Code Editor (OCE) and Medicare Physician Fee Schedule updates, the descriptors of these codes will change to reflect the revised coverage policy
The following revised descriptors reflect the expanded NCD criteria and are effective for services on or after March 19, 2008 as follows:
Long Descriptor G0248: Demonstration, prior to initial use, of home INR monitoring for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of 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 patient ability to perform testing prior to its use.
Short Descriptor G0248: Demonstrate use home INR mon
Long Descriptor G0249: Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; not occurring more frequently than once a week
Short Descriptor G0249: Provide INR test mater/equipm
Long Descriptor G0250: Physician review, interpretation, and patient management of home INR testing for a patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes face-to-face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring; not occurring more frequently than once a week.
Short Descriptor G0250: MD INR test revie inter mgmt
Note: Test materials continue to include 4 tests. Frequency of reporting requirements shall remain the same.
Note: Porcine valves are not included in this NCD, so Medicare will not make payment on Home INR Monitoring for patients with porcine valves unless covered by local Medicare contractors.
Note: This NCD is distinct from, and makes no changes to, the PT clinical laboratory NCD at section 190.17, of the NCD Manual.
The following are applicable diagnosis codes to be used when submitting claims to Medicare contractors:
For services furnished on or after March 19, 2008, the applicable ICD-9-CM diagnosis codes for this benefit are:
V43.3 (organ or tissue replaced by other means; heart valve);
289.81 (primary hypercoagulable state);
451.0-451.9 (phlebitis & thrombophlebitis);
453.0-453.3 (other venous embolism & thrombosis);
415.11-415.19 (pulmonary embolism & infarction); or
427.31 (atrial fibrillation (established) (paroxysmal))
Medicare contractors will deny claims for PT/INR monitoring services that are not delivered in accordance with CR6138. Denied claims are subject to appeal. When denying such claims, your Medicare carrier, FI or A/B MAC will use the following codes:
Remittance Advice Remark Code N386, "This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp on the CMS website. If you do not have Web access, you may contact the contractor to request a copy of the NCD."
Claim Adjustment Reason Code 50 will be used: "These are non-covered services because this is not deemed a ‘medical necessity’ by the payer."
Providers should be aware that your Medicare Contractor will assign liability for the denied charges to you unless documentation of an Advance Beneficiary Notice (ABN) is present on the claim. Also, your contractor will not search for claims but will adjust inappropriately denied claims with dates of service March 19, 2008, through the implementation date of CR6138, that are brought to their attention.
Additional Information
CR6138 was issued in two transmittals, i.e., one for the NCD Manual and one for the Medicare Claims Processing Manual. These transmittals are available at http://www.cms.hhs.gov/Transmittals/...ads/R90NCD.pdf and http://www.cms.hhs.gov/Transmittals/...ds/R1562CP.pdf, respectively, on the CMS website.
If you have questions, please contact your Medicare A/B MAC, FI or carrier at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/d...mDirectory.zip on the CMS website.
Effective Date: March 19, 2008; Implementation Date: August 25, 2008
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