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I'm having difficulty understanding the correct way to bill for coumadin checks to Medicare.

The family practice I bill for uses the following codes:

85610-QW, GA

The 85610 gets paid but the 36416 does not. And since it's done by fingerstick, G0001/36415 does not apply. The Medicare rep told me that 36416 bundles with any other procedure or line item on the claim. But I have searched all the CCI edits and can't find that it does.

The commercial carriers will pay for the 36416 with the -59 modifier.

The office manager of the office I bill for is persistent that there must be a way another code to use, because she said they are losing money on these, especially if the patient comes in for office visit with the doctor on the same day. They only get reimbursed the 5.42 on the 85610 - ouch!

Any suggestions?

You didn't mention if the 99212 is being paid or not.  It looks like it is coded properly, if they are bundling the 36416 the way you have it coded I am not sure there is anything you can do.  You could ask for a review and state why you disagree with the bundling.

Good luck

HI Michelle,

They pay for the 99212 if they come in just for the coumadin. But in that case, is the -25 modifier even appropriate since the 85610 is the reason for the visit.

~ Charity

Steve Verno CMBS, CEMCS:
IM on Coumadin.  My cardiologit established a Coumdin clinic within his practice.  The coumadin checks are done by the practice nurse on Tuesdays only. That is when my cardiologist is in the office.  The Coumadin checks are done as part of Incident to services. The nurse does a finger stick and voila, I am within Coumadin parameters or I need an increase/decrease in doseage. 

They bill the following:  99211 (25) and 85610. 

All claims are paid by my Government Insurance Carrier. My insurance pays $5.54 for the 85610.

On a side note, we DONT code because an office manager doesnt like what is being paid for services rendered and because that payment is low.  To find another code as a means of increasing revenue, when that code is not appropriate for what was documented and performed, could be called upcoding and upcoding may be illegal in many states and it could be called fraud.

With me, the 99211 is appropriate because it follows Incident To rules. 



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