Noridian is issuing this coding and billing guidance as it relates to the National Coverage Determination for Home Prothrombin Time/International Normalized Ration (PT/INR) Monitoring for Anticoagulation Monitoring (NCD 190.11) and is in no way a change in coverage as outlined in the NCD and MLN Matters articles.
This NCD provides coverage for home testing of the PT/INR for those beneficiaries who meet the criteria for coverage in the NCD language.
For the purpose of billing and coding the following guidelines are promulgated and are effective immediately.
- The coverage is for one home test per week. For the purpose of this direction a week is considered a calendar week, Sunday through Saturday.
Providers may only bill Noridian for this service when the fourth test is completed and the results submitted to the treating physician. In the event the beneficiary either withdraws from home testing, dies or transfers to a Medicare Advantage or similar program, a claim for partial billing is allowed when appended with a -52 modifier. Noridian will pay a pro-rated amount based on the number of tests fully completed and reported to the treating physician. No payment is available for unused tests. As use of this code G0249 is for completion of four INR services, in the rare event that it is known services will not continue and a claim must be filed for fewer, use the code with the modifier -52 appended and decrement the charge in direct proportion to the number that have been completed (75%, 50% or 25%). For such partial billings submit the following claim information:
- The number of tests completed shall be in the comment/narrative field for the following Part B claim field/types:
- Loop 2400 or SV101-7 for the 5010A1 837P
- Item 19 for paper claim
- The number of tests completed shall be in the comment/narrative field for the following Part A claim field/types:
- Line SV202-7 for 837I electronic claim
- Block 80 for the UB04 claim form
2. Noridian realizes that on rare occasions a beneficiary may inadvertently test twice in one week or may elect to test “early” for the next week due to personal situations. These exceptions may be allowed as long as the clinical records indicate a reasonable cause for the early testing and no more than four tests in four weeks are submitted. Such “early” testing is not expected to be the norm and does not allow for payment for more than 4 tests (one unit of service (UOS) in four weeks.
3. Should a situation occur where the beneficiary needs additional testing, for example an abnormal INR on a home test, such added home testing is not covered using the G0249 code. The beneficiary may be tested in the physician’s office or a clinical lab in the usual manner for outpatient testing. If they prefer to do a repeat home test(s) and such is approved by their provider and a written order received, payment for such extra tests are the responsibility of the beneficiary. Noridian recommends that an ABN be given to the patient and the appropriate ABN modifier appended to any claim with the extra tests.
4. A Unit of Service is four tests. One unit of G0249 is therefore four tests which have been completed and reported to the provider over a period of four weeks or greater. The billing date of service is either on or after the completion and reporting of the fourth test.
- CMS Internet Only Manual (IOM), Publication Medicare National Coverage Determination (NCD); Part 2, Section 190.11.
- CMS Change Request 6397, Dated March 4, 2009-April Update to the 2009 Medicare Physician Fee Schedule Database (MPFSDB)
- MLN Matters Article MM6397