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Billing of G0249 by IDTF(Independent diagnostice testing facility)

Armando Posted Wed 06th of September, 2017 14:39:48 PM
Our specialty is IDTF and we are registered with Medicare with the same. We are billing Pos#12 and four Dos with CPT G0249 per month on the CMS-1500 form. Until May-2017 we were getting paid for all four CPTs per month. Now Medicare is denying those claims stating CO-119 -Benefit maximum for this time period or occurrence has been reached, N362-The number of Days or Units of Service exceeds our acceptable maximum, and N704- You may not appeal this decision but can resubmit this claim/service with corrected information if warranted. Some other provider with same specialty (IDTF) while billing on CMS-1500 getting paid for G0249 for all four DOS (tests) per month. Can you show us a way how to bill these services to get paid for all four DOS (Test) per month from Medicare?
SuperCoder Answered Thu 07th of September, 2017 07:08:35 AM


Code G0249 testing is limited to once per week, and G0249 requires that four tests be performed and results reported to the physician. Are your four DOS are within the time frame of once per week? If yes than, that should be paid by medicare as there are no recent changes for reporting code G0249.

Armando Posted Thu 07th of September, 2017 13:28:48 PM
Yes, All four DOSs are within the time frame of once per week and still we are getting denials as stated above. Medicare isn't paying and also advising they will cover only one DOS for G0249 once in 28 days. Are we billing the correct POS#12 and correct CMS-1500 form? Do we need to bill with any modifier and we are billing this for IDTF specialty. We were getting paid for all four DOS per month until May-2017 by Medicare. We are losing lots of money because of it. How to get paid for all four DOS of G0249?
SuperCoder Answered Fri 08th of September, 2017 02:32:22 AM

Hi Armando,

Below is the supercoder Path/lab coding alert that will help you understand the appropriate reporting of G0249 for medicare. As per the article G0249 include 4 test at different DOS, once every week and reported once in 28 days.


Avoid G0250 frequency pitfall.

In addition to ordering a Prothrombin Time (PT) lab test, physicians might ask certain patients to perform home PT monitoring to manage warfarin (trade name Coumadin) dosage.

When patients perform the test at home to determine the PT reading (in seconds) and/or the International Normalized Ratio (INR), you’ll need to know a whole different set of coverage rules and codes than you read about in “3 Tips Show You How to Correctly Code PT Lab Tests” on page 75. Here’s the lowdown on these services:

Look at Coverage and Coding

In addition to the lab NCD for PT testing (190.17), Medicare provides a distinct NCD, 190.11 (Home PT/ INR) for home testing. Unlike coverage for the lab test that is broadly supported as medically necessary for many conditions, CMS limits coverage for home PT/INR monitoring to patients with specific conditions who are taking warfarin. The covered conditions are mechanical heart valve, chronic atrial fibrillation, or venous thromboembolism. The case must also meet the following conditions to be eligible for Medicare coverage:

  • A treating physician must prescribe home PT/INR monitoring
  • Patient must have been anticoagulated for at least three months
  • Patient must participate in face-to-face educational program on anticoagulation management and demonstrate correct device use
  • Patient should not self-test more than once a week.

Hint: Local Medicare contractors may cover the service for a broader range of conditions, such as warfarin monitoring for patients with porcine heart valves. Always check coverage rules with your individual payers.

Use these codes: You have the following three codes to describe home PT/INR management for Medicare beneficiaries:

  • G0248 (Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient’s ability to perform testing and report results)
  • G0249 (Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests)
  • G0250 (Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve[s], chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests)

Avoid Common Payment Snags

You can see that codes G0248 and G0250 require the service of a physician (or qualified healthcare provider). For instance, a pathologist may perform these tasks as part of a “Coumadin Clinic” to monitor coagulation therapy for patients.

Watch frequency: Medicare provides limitation for how often you can use each of the codes to bill for the service. You can report G0248 just once in a patient’s lifetime, while you can bill G0249 and G0250 once every four weeks.

Specifically: Physicians should only bill G0250 once every 28 days. If the physician submits G0250 before the 28 full days have passed, Medicare will deny your claim.

Pitfall: Many physicians want their patients to perform the test more frequently than once per week when the test result isn’t optimal (too high or low), according to Ray Cathey, PA, FAAPA, MHS, MHA, CCS-P, CMSCS, CHCI, CHCC, president of Medical Management Dimensions in Stockton, California. If the provider bills G0250 with the understanding that the code is “per four tests” without the caveat that the test is covered once per week, that can lead to claims denials.

Even if the patient performs the test more often than once per week per the physician instructions, you can expect payment for the testing only once every 28 days.

Management tip: Meeting the time restriction for G0250 is essential, but how can you make sure you’re on the right track? “Since Medicare has specific timing parameters for the coverage of HCPSC code G0250, the frequency limitation information should be shared with the practitioners and billing staff to assist in operational billing and reimbursement processes,” says Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska.

“Consider incorporating flags/edits in the billing software for G0250 to help ensure 28 full days have passed (not occurring more than once a week, billing units of service include four weeks), to avoid claim denials,” Swanson suggests.

Swanson also recommends that practices implement an internal policy and procedure for reporting G0250 outlining Medicare’s coverage, billing, and reimbursement policy.

Qualified personnel: Staff other than the physician may obtain test results from the patient, but the physician must review and interpret the results, according to Cathey. “These test results must be documented in the patient record,” Cathey says. “It is recommended that the physician acknowledge his/her review of all test results thus documented.”

Carefully Document Dx and Testing

Make sure the medical record demonstrates each component that indicates compliance with the payer coverage requirements.

Documentation for G0250 should include the following elements:

  • date of test
  • diagnosis of a covered condition, such as I48.2 (Chronic atrial fibrillation)
  • the target INR range
  • the patient test result.

“Additionally, medical record documentation should support the physician’s order, test result review, interpretation, and patient management of home INR testing,” Swanson says.

Patient instructions: Be sure to document communicating the test interpretation, and any medication changes, to the patient or representative.

“I would also suggest that the statement include a comment such as ‘the patient (or representative) appears to understand’ the new instructions,” Cathey says. “And the physician review/signature is required.”

Hope that helps! Please let me know if you have any other query.

Armando Posted Mon 11th of September, 2017 14:28:15 PM
We are using the same documentations and dx code as per the guideline but still, we did not receive four test payment. We received one test payment and other three test were denied due to a frequency reason with reason code CO-119 in Medicare. I need a solution How Medicare remove this frequency denial in other three tests. If you need any patient information which we got a denial from Medicare we will provide.
SuperCoder Answered Tue 12th of September, 2017 03:40:13 AM

As i answerred above as well, HCPCS code G0249 and G0250 includes 4 tests, which can be reported under 28 days, i.e., 1 test every week.

But for whole 28 days, you can bill only 1 billing unit of these HCPCS codes.

User can bill the HCPCS code with just start date, on which test was initiated or can enter the start and end date range of 28 days on a single claim line of CMS-1500 form with only 1 unit.

You are over-billing the units, thtswhy medicare dnied. 

Hope that helps!

Armando Posted Fri 13th of October, 2017 16:17:00 PM
Can we append modifier GY on these services(G0249)? In which condition modifier GY should be appended?
SuperCoder Answered Mon 16th of October, 2017 03:34:38 AM

Appending -GY modifier to the CPT code enables one to identify an “item or service is statutorily excluded or the service does not meet the definition of Medicare Benefit”. This will automatically create a denial and beneficiary may be liable for all charges whether personally or through other insurance, ( for example: when a beneficiary wants new eye glasses and wants to get a denial through Medicare for secondary payer purposes), claim should be submitted with -GY modifier. This way claim may be processed faster than it would be without -GY modifier. ABN’s ( Advanced Beneficiary Notices) are not an issue for statutory exclusions.

G0249 is covered by  medicare. So, why are you billing with GY modifier?

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