Pharmacy Question for the Week of August 6, 2018

Pharmacy Compliance Question of the Week


We have a Coumadin clinic at our facility. The patients are seen by a Coumadin nurse who does a full assessment on the patient she sees every month. During the assessment she also does a PT/INR check on the patient. Is it appropriate to bill the evaluation and management (E & M) level G0463 and the PT/INR check 85610. We have been struggling with this issue for a while and would like some clarifications as soon as possible.


Routinely reporting E & M visit code G0463 with the other services rendered may present some risk. Reporting an outpatient E & M visit level still requires medical necessity to be documented.

In the past, Medicare Administrative Contractors (MACs) have stated that if the sole purpose of a visit is to draw blood or give an injection, then the E & M visit code should not be billed only the service rendered. Should the patient present for the regularly scheduled visit, and the patient voices concerns to the nurse (e.g., side effects of medication, bruising, unexplained bleeding, etc.) or requires a dosage change based on the results of the PT/INR or presenting problem, the nurse will need to document the patient history, any exam, any dosage change, discussion with physician, and patient instructions in the medical record for review by the supervising physician. This is a limited example that would help support billing an outpatient E/M visit in addition to code 85610 (PT/INR). Otherwise, the clinic may only report the code for the test when the nurse performs/documents an assessment and performs the test.

We recommend the clinic staff review any payer coverage guidelines for anticoagulation clinic services to ensure appropriate coding and billing.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.