Highmark Medicare Services Position on the Necessity of E/M Services Submitted as a Component Service of Anti-Coagulation Management

Highmark Medicare Services continues to experience both questions and confusion regarding the billing of 99211, (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician), in addition to the laboratory blood draws for warfarin management.
An evaluation and management (E/M) service (99211) would be allowable if it is determined that the patient’s medication needs adjustment, the INR is not therapeutic, or if the patient has symptoms that need to be addressed.

The billing of an E/M service in addition to obtaining the clinical specimen (phlebotomy or fingerstick) is not medically reasonable and necessary if the following conditions are met:
If the INR is within the therapeutic range, and

  1. the documentation does not support a need for adjustment of warfarin dosage, or
  2. the documentation does not support that the patient is symptomatic, or
  3. the documentation does not support the presence of a new medical co-morbidity or dietary change. 

Rather, information may be relayed to the beneficiary telephonically, and there is no need for a face-to-face E/M service.
In this clinical setting, the medical necessity of a unique clinical service may be predicated upon the clinical circumstances of a previous visit, i.e., a significantly sub or supra-therapeutic INR necessitates quick follow-up.  Use of a flow sheet and established protocol helps to provide both good patient care and documentation of medical necessity in these cases.  Documentation of the services provided by the physician or nurse, discussion of symptoms, side effects, patient observations, etc. are considered supportive of the 99211 service.

The American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy suggests that the INR be checked daily until the therapeutic range has been reached and sustained for two consecutive days, then 2 or 3 times weekly for 1 to 2 weeks, and then less often based on stability of results.  Once the INR becomes stable, the frequency of testing can be reduced to intervals as long as 4 weeks.  Highmark Medicare Services expects to see the educational component of anticoagulation management reflected in the use of 99211 in the early post-initiation visits, and less frequently as the stable target of anti-coagulation is reached.  Two cited European studies make a strong case for Patient Self-Testing and Management, in which case, the patient education would be documented within the appropriate level of an established E/M service, where time/counseling service guidelines would apply.