(Reproduced by permission from Medicare Focus, August, 1997, pp. 45 - 48.)

Medicare Part A
Local Medical Review Policy
Prothrombin Time

Policy Number: 96-11

Description

85610

Prothrombin Time

Type of Bill: 13X, 14X, 22X, 23X, 71X, 74X, 75X

Revenue Codes: 300-319

Indications and Limitations

This test is performed to evaluate the extrinsic coagulation system, evaluate deficiency of prothrombin, dysfibrinogenemia, afibrinogenemia (complete), heparin effect, coumadin or warfarin effect, liver failure, disseminated intravascular coagulation (DIC), and Vitamin K deficiency.

HCPCS Codes: 85610

Diagnosis Codes for Coverage

ICD-9 diagnosis codes should be used at their highest level of specificity.

Category: Pathology and Laboratory

Reason for Denial

Routine screening

Noncovered Diagnosis Codes

Screening for congenital deficiences of factors II, V, VII, and X are not covered. In addition, prothrombin time testing performed for indications other than those listed above will be considered not medically necessary or reasonable and will result in denial of coverage.

Sources of Information

1996 CPT Book, American Medical Association, p.312
Diagnostic Tests Handbook, Springhouse Corporation, 1987
Laboratory and Diagnostic Tests, Fifth Edition, Lippincott, 1996
Other Carriers' Policies

Coding Guides

Use 85610 when billing for a prothrombin time test.

Documentation Required

ICD-9-CM diagnosis codes are required on claim.

Medical records must clearly document the medical necessity for the test and the frequency of the test.

If documentation is requested for review, submit the following:

• History and Physical
• MD orders/progress notes
• Diagnosis/reason for test
• Test results
• Itemization of charges

Comments

This policy is being adapted from the Carrier policy. It does not represent the sole opinion of the Intermediary/Medical Director. This policy was developed in consultation with the medical community and the Carrier Advisory Committee.

Approval Dates