Use of the International Normalized Ratio (INR) or prothrombin time (PT) – standard measurement for reporting the blood's clotting time – allows physicians to determine the level of anticoagulation in a individual, independent of the laboratory reagents used. The INR is the ratio of the individual’s PT (extrinsic or tissue-factor coagulation pathway) compared to the mean PT for a group of normal individuals.
The use of home PT/INR monitoring for chronic, oral anticoagulation management may be considered medically necessary for when ALL of the following criteria are met:
· The individual has ONE of the following:
o Mechanical heart valves; or
o Chronic atrial fibrillation; or
o Venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism); and
· The individual is currently taking Warfarin; and
· The individual must have been anticoagulated for at least three (3) months prior to use of the home INR device; and
· The individual 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
· The individual continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and
· Self-testing with the device should not occur more frequently than once a week; and
· The monitor and the home testing must be prescribed by a treating physician.
The use of home PT/INR will not be considered medically necessary for any other indications.
Payment will not be made for home INR monitoring for individuals with porcine valves.
93792 |
93793 |
G0248 |
G0249 |
G0250 |
|
|
Procedure code G0249 includes payment for both the device and the supplies. These items may not be separately billed. Procedure code G0249 includes materials for four (4) tests. Therefore, this code should not be billed more than once every four (4) weeks.
Procedure code G0250 is per four (4) tests. Self-testing with the INR monitor is limited to once weekly. Therefore, this code should not be billed more than once every four (4) weeks.
Covered Diagnosis Codes for Procedure Codes 93792 93793 G0248 G0249 G0250
D68.51 |
D68.52 |
D68.59 |
D68.61 |
D68.62 |
I26.01 |
I26.02 |
I26.09 |
I26.90 |
I26.92 |
I26.93 |
I26.94 |
I26.99 |
I48.0 |
I48.11 |
I48.19 |
I48.20 |
I48.21 |
I48.91 |
I80.00 |
I80.01 |
I80.02 |
I80.03 |
I80.10 |
I80.11 |
I80.12 |
I80.13 |
I80.201 |
I80.202 |
I80.203 |
I80.209 |
I80.211 |
I80.212 |
I80.213 |
I80.219 |
I80.221 |
I80.222 |
I80.223 |
I80.229 |
I80.231 |
I80.232 |
I80.233 |
I80.239 |
I80.241 |
I80.242 |
I80.243 |
I80.249 |
I80.251 |
I80.252 |
I80.253 |
I80.259 |
I80.291 |
I80.292 |
I80.293 |
I80.299 |
I80.3 |
I80.8 |
I80.9 |
I82.0 |
I82.1 |
I82.220 |
I82.221 |
I82.3 |
I82.401 |
I82.402 |
I82.403 |
I82.409 |
I82.411 |
I82.412 |
I82.413 |
I82.419 |
I82.421 |
I82.422 |
I82.423 |
I82.429 |
I82.431 |
I82.432 |
I82.433 |
I82.439 |
I82.441 |
I82.442 |
I82.443 |
I82.449 |
I82.451 |
I82.452 |
I82.453 |
I82.459 |
I82.461 |
I82.462 |
I82.463 |
I82.469 |
I82.491 |
I82.492 |
I82.493 |
I82.499 |
I82.4Y1 |
I82.4Y2 |
I82.4Y3 |
I82.4Y9 |
I82.4Z1 |
I82.4Z2 |
I82.4Z3 |
I82.4Z9 |
I82.91 |
T80.0XXA |
T81.718A |
T81.72XA |
T82.817A |
T82.818A |
Z79.01 |
Z95.2 |
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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.