Coumadin Clinic

[Cowboys_RN, BSN]

I am looking into setting up billing for a Coumadin Clinic we want to start in my office. It looks like most Coumadin Clinics that are ran by pharmacists are billed use the E/M code 99211 and they bill "Incident To" a supervising physician. The regulations say the supervising physician has to do an initial visit with the patients.

I'm wondering if anyone has experience with these types of clinics? If so, what does the initial visit with the physician consist of? Is it just a quick meet and greet or an actual visit? What E/M code is billed?

[T-Bird78]

Not sure about billing codes, but when I worked in a cardio office it was a nurse visit, walk-in basis. Pts were already established at the practice and rx the coumadin and frequency of visit. Pt would sign in at a separate area, finger stick done and processed, and dose adjustment made by RN (if necessary). As pts got more stable they'd need less frequent coumadin clinic visits but maintian regular follow up visits with the MD or midlevel provider. Coumadin clinic was billed as just a nurse visit. Hope that helps.

[RainMom]

First off, I've never been involved with a coumadin clinic so.....this may or may not be helpful.

Been a while since I've dealt with CPT codes, but I wouldn't think that you could use 99211 unless there is direct physician contact,not just a pharmacist. I know there is specific coding for nutritional management which would then have modifier -25 added to indicate it as a separately identifiable procedure from the Evaluation/Management code (the 99211, -12, -13, etc). Pretty sure there should be a separate code for medication management.

A quick search shows E/M codes (99211 etc) can only be used by physicians, NPs, PAs, nurse midwives.

As far as what to bill on the pt's first visit with the physician...do you have a CPT book? That would depend on various factors such as amt of time spent, extent of exam (# of body systems involved), degree of difficulty in decision making, extent of history taken, new pt vs old pt. I would think for what you're talking about, it would be a pretty focused visit, 99212/99202.

[Cowboys_RN, BSN]

Thanks for the feedback :) The only way that the pharmacists can bill using 99211 is using something called "incident to" billing. It requires physician supervision but does not require a face-to-face with the physician at each visit. We do however need to have a physician personally perform an initial visit. Medicare regulations just say an initial visit, it doesn't define what the initial visit needs to entail. If it can just be a quick visit we would bill 99201/99212. If it has to be more involved we would bill 99202/99213. I'm hoping for the quick visit. I'll continue with my research.

At my last place the Coumadin Clinic was ran by RNs not pharmacists. We billed 99211 as a nurse visit. It was much easier than figuring out billing with a pharmacist.