Home PT/INR For HCPCS G0250 Coverage & Limitations

Long Description CPT 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.

For services furnished on or after July 1, 2002, the applicable ICD-9-CM diagnosis code for this benefit is only V43.3 (organ or tissue replaced by other means; heart valve). 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 – Phlebitis and thrombophlebitis: of superficial vessels of lower extremities: saphenous vein (greater) (lesser)

451.11 – Phlebitis and thrombophlebitis: of deep vessels of lower extremities: femoral vein (deep) (superficial)

451.19 – Phlebitis and thrombophlebitis: of deep vessels of lower extremities: other (femoropopliteal vein popliteal vein tibial vein)

451.2 – Phlebitis and thrombophlebitis: of deep vessels of lower extremities: other (femoropopliteal vein, popliteal vein, tibial vein)

451.80 – Phlebitis and thrombophlebitis: of other sites

451.81 – Phlebitis and thrombophlebitis: of other sites: iliac vein

451.82 – Phlebitis and thrombophlebitis: of other sites: of superficial veins of upper extremities (anticubital vein, basilic vein, cephalic vein)

451.83 – Phlebitis and thrombophlebitis: of other sites: of deep veins of upper extremities (brachial vein, radial vein, ulnar vein)

451.84 – Phlebitis and thrombophlebitis: of other sites: of upper extremities, unspecified

451.89 – Phlebitis and thrombophlebitis: of other sites: other

451.9 – Phlebitis and thrombophlebitis: of other sites: of unspecified site

453.0 – Other venous embolism and thrombosis: Budd-Chiari Syndrome (hepatic vein thrombosis)

453.1 – Other venous embolism and thrombosis: thrombophlebitis migrans

453.2 – Other venous embolism and thrombosis: of vena cava

453.3 – Other venous embolism and thrombosis: of renal vein

453.40 – Venous embolism and thrombosis of deep vessels of lower extremity: venous embolism and thrombosis of unspecified vessels of lower extremity (deep vein thrombosis NOS, DVT NOS)

453.41 – Venous embolism and thrombosis of deep vessels of lower extremity: venous embolism and thrombosis of deep vessels of proximal lower extremity (femoral, iliac, popliteal; thigh, upper leg NOS)

453.42 – Venous embolism and thrombosis of deep vessels of lower extremity: venous embolism and thrombosis of deep vessels of distal lower extremity (calf, lower leg NOS; peroneal, tibial)

453.8 – Venous embolism and thrombosis of deep vessels of lower extremity: of other specified veins

453.9 – Venous embolism and thrombosis of deep vessels of lower extremity: of unspecified site

415.11 – Pulmonary embolism and infarction: iatrogenic pulmonary embolism and infarction

415.12 – Pulmonary embolism and infarction: septic pulmonary embolism

415.19 – Pulmonary embolism and infarction: other

427.31 – Atrial fibrillation (established) (paroxysmal)

Coverage:

1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and,

2. 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,

3. 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,

4. Self-testing with the device should not occur more frequently than once a week.

Limitations

HCPCS code CPT G0250 should be billed no more than once every four weeks, since the code descriptor is per four tests.

References: https://www.cms.gov/transmittals/downloads/R1562CP.pdf

CR Transmittal # R1663CP, MLN Matters MM6313