Provider Manual


Anticoagulation management billing

Anticoagulation therapy is widely used to prevent and treat thromboembolic disorders, most commonly associated with mechanical valves, atrial fibrillation, postcerebrovascular accident, acute myocardial infarction, pulmonary embolism, and other valvular heart disease.

  • Patients are monitored closely for response to the therapy and the development of potentially serious complications. Close monitoring improves care and reduces risk.
  • These services are outpatient only for commercial plans.
  • Priority Health Medicare: Billing for home prothrombin time INR monitoring for anticoagulation management for certain conditions is specified under National Coverage Determination (NCD) 190.11.

Anticoagulation therapy codes

There are two codes for anticoagulation management that are covered for all programs.

Initial 90 days: Use CPT code 99363

  • Use for the initial 90 days of management of outpatient warfarin therapy
  • Covers the work in adjusting warfarin levels based on review of a patient's INR measurements
  • Reporting requires that a physician record at least 8 INRs in the 90-day period.

Subsequent 90-day periods: Use CPT code 99364. Reporting requirement is only 3 INR measurements.

Coding help

  • The work of anticoagulant management may not be used as a basis for reporting an E&M service or Care Plan Oversight time.
  • Codes are reportable for face-to-face and telephone visits, but not in addition to telephone or online services codes.
  • When anticoagulation therapy is initiated or continued in the inpatient or observation setting, a new period begins after discharge and is reported with 99364.
  • If a separately identifiable E&M service is performed, report the appropriate E&M service code using modifier 25.
  • Report modifier 52 when a component of a CPT code definition is reduced or eliminated. Append modifier 52 to the CPT code that represents the basic service to indicate that the basic service was performed but a one component of the service/CPT code definition was not. Reimbursement will be 50% of the base fee schedule. See more about using modifier 52.
Last modified: 6/15/2017
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