Does G0249 require prior authorization?

No, G0249 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for G0249?

Medicare facility rate: $65.80. Non-facility rate: $65.80. Work RVU: 0.00.

Verity

`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

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

$65.80

Non-Facility

$65.80

Documentation Required

The number of completed tests must be included in the claim narrative for Part B: 5010A1 837P Loop 2400 or SV101-7 for electronic claims, and Item 19 for paper claims.
For Part A submit the number of completed tests in Line SV202-7 on the 837I electronic claim or Block 80 on the UB-04 form.

Clinical records must document test results and, when early/duplicate testing is claimed, the reasonable clinical cause for the early test(s).

When partial billing is submitted because testing will not continue (withdrawal, death, transfer), append modifier -52 and indicate the number of tests completed; charges must be decremented proportionally (75%, 50%, or 25%).

If extra home tests will be charged to the beneficiary, the provider should obtain a written order and provide an Advance Beneficiary Notice (ABN) and append the appropriate ABN modifier to the claim.

Retain and provide copies of hard-copy output with analysis of all data (including bidirectional vascular flow or imaging when provided) in the patient record.

Key Coverage Criteria

Medicare covers home PT/INR monitoring using HCPCS G0249 for beneficiaries who meet the coverage criteria in Medicare NCD 190.11.
Coverage is for one home PT/INR test per calendar week (Sunday–Saturday) with billing occurring after completion and reporting of four tests to the treating physician (one unit of service).
Perform peripheral venous ultrasound to evaluate clinical signs or symptoms suggestive of acute or new-onset deep vein thrombosis (e.g., extremity swelling, tenderness, erythema).
Perform venous ultrasound to investigate DVT as the source of a confirmed pulmonary embolism.
Repeat or perform venous ultrasound for patients with known venous thrombosis who have a clinical change and where documented change in thrombus burden would alter management or therapy.
Perform venous ultrasound to evaluate postthrombotic (postphlebitic) syndrome in patients with symptoms consistent with PTS (e.g., chronic leg pain, heaviness, swelling, itching, or leg ulcers).

10 Active Policies

L33693 — Peripheral Venous Ultrasound

J09

L37371 — Electroretinography (ERG)

J12

L35007 — Vestibular and Audiologic Function Studies

J12

L35434 — Oximetry Services

J12

L35451 — Peripheral Venous Ultrasound

J12

A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

J12

AETNA-CPB-0173 — Prothrombin Time (INR) Home Testing Devices

ANTHEM-CG-DME-30 — CG-DME-30 Prothrombin Time Self-Monitoring Devices

A55754 — Billing and Coding: Home PT/INR Monitoring (G0249) Billing and Coding

A57807 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

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