Local Coverage Article Billing and Coding

Billing and Coding: Home PT/INR Monitoring (G0249) Billing and Coding

A55754

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Contractor Information

Article Information

General Information

Article ID
A55754
Article Title
Billing and Coding: Home PT/INR Monitoring (G0249) Billing and Coding
Article Type
Billing and Coding
Original Effective Date
10/09/2017
Revision Effective Date
04/29/2020
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

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.

  1. 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:

  1. 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
  2. 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.

 Sources:

  • 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

Coding Information

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

G0249

Group 1 Codes

N/A

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
52 REDUCED SERVICES: UNDER CERTAIN CIRCUMSTANCES A SERVICE OR PROCEDURE IS PARTIALLY REDUCED OR ELIMINATED AT THE PHYSICIAN'S DISCRETION. UNDER THESE CIRCUMSTANCES THE SERVICE PROVIDED CAN BE IDENTIFIED BY ITS USUAL PROCEDURE NUMBER AND THE ADDITION OF THE MODIFIER -52, SIGNIFYING THAT THE SERVICE IS REDUCED. THIS PROVIDES A MEANS OF REPORTING REDUCED SERVICES WITHOUT DISTURBING THE IDENTIFICATION OF THE BASIC SERVICE. MODIFIER CODE 09952 MAY BE USED AS AN ALTERNATIVE TO MODIFIER -52. NOTE: FOR HOSPITAL OUTPATIENT REPORTING OF A PREVIOUSLY SCHEDULED PROCEDURE/SERVICE THAT IS PARTIALLY REDUCED OR CANCELLED AS A RESULT OF EXTENUATING CIRCUMSTANCES OR THOSE THAT THREATEN THE WELL-BEING OF THE PATIENT PRIOR TO OR AFTER ADMINISTRATION OF ANESTHESIA, SEE MODIFIERS -73 AND -74 (SEE MODIFIERS APPROVED FOR ASC HOSPITAL OUTPATIENT USE).

ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
04/29/2020 R1

Converted to billing and Coding article and added G0249 to the CPT/HCPCS Codes section and 52 modifier to the CPT/HCPCS Modifiers section. No change in coverage was made.

 

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/13/2021 04/29/2020 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Home
  • PT/INR
  • INR
  • G0249
  • Testing
  • modifier 52