Medicare Advantage Medical Policy Bulletin

Section: Diagnostic Medical
Number: M-61
Topic: Home Prothrombin Time International Normalized Ratio (INR) Monitoring for Anticoagulation Management
Effective Date: August 1, 2005
Issued Date: February 12, 2007

General Policy

For services on or after December 31, 2007, see policy N-7.

Use of the International Normalized Ratio (INR) allows physicians to determine the level of anticoagulation in a patient, independent of the laboratory reagents used. The INR is the ratio of the patient’s prothrombin time compared to the mean prothrombin time for a group of normal individuals.

Maintaining patients within the therapeutic range minimizes adverse events associated with inadequate or excessive anticoagulation, such as serious bleeding or thromboembolic events. 

Patient self-testing and self-management through the use of a home INR monitor may be used to improve the time in therapeutic rate (TTR) for select groups of patients. Increased TTR leads to improved clinical outcomes and reductions in thromboembolic and hemorrhagic events.

Indications and Limitations of Coverage

The use of home prothrombin time INR monitoring is covered for anticoagulation management for patients with mechanical heart valves on warfarin when all the following criteria are met:

  1. A physician must prescribe the monitor and the home testing;
  2. The patient must have been anticoagulated for at least three months prior to use of the home INR device;
  3. The patient must undergo an educational program on anticoagulation management and the use of the device prior to its use in the home; and
  4. Self-testing with the device is limited to a frequency of once per week.
NOTE:
Special consideration may be given in individual situations for homebound patients receiving anticoagulant therapy who do not have a mechanical heart valve, when visits to a laboratory for prothrombin time testing are not possible due to the patient's medical condition.

Porcine valves are not covered. Therefore, no payment will be made for home INR monitoring for patients with porcine valves.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

G0248G0249G0250   

Coding Guidelines

Procedure code G0249 includes payment for both the device and the supplies. These items may not be separately billed. Procedure code G0249 is not covered as durable medical equipment.

Procedure code G0250 is per four tests. Self-testing with the INR monitor is limited to once weekly. Therefore, this code should not be billed more than once every four weeks.

References

NCD for Home Prothrombin Time INR Monitoring for Anticoagulation Management (190.11)

Transmittal AB-02-180, CR 2323

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

V43.3   

Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.