CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Home Prothrombin Time Monitoring

Defines coverage and billing for at-home prothrombin time/INR monitoring (home INR monitoring) for patients on chronic warfarin anticoagulation for Medicare Advantage and commercial products, including separately reimbursed CPT/HCPCS codes and conditions (e.g., mechanical heart valves, chronic atrial fibrillation, venous thromboembolism).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Home Prothrombin Time Monitoring

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2025

Next Review Date

Key ActionProvide face-to-face demonstration prior to initiation, obtain at least one blood sample, instruct on reporting home INR results, and document patient's/caregiver's ability to perform testing and report results.

SourceLink

POLICY UPDATE CHANGES

No material changes.

3Common covered indications listed

5Separately reimbursed codes listed

Coverage Summary & Scope

Scope: Defines coverage and billing for at-home prothrombin time/INR monitoring (Home INR monitoring) for patients on chronic warfarin anticoagulation, including separately reimbursed CPT/HCPCS codes and qualifying conditions such as mechanical heart valves, chronic atrial fibrillation, and venous thromboembolism. Coverage stance: Covered with criteria when Medicare Advantage and commercial plan criteria are met. Effective date: 2025-04-01. Last review: 2025-07-02.

Medically Necessary Criteria

Medically Necessary Criteria for At-Home INR Monitoring

At-home monitoring of chronic warfarin therapy may be considered medically necessary when ALL of the following apply:

ALL of the following

Examples of qualifying chronic medical conditions (ONE or more):
- Mechanical heart valve(s)
- Chronic atrial fibrillation
- Venous thromboembolism
- Other chronic medical conditions requiring continuous anticoagulation
Home prothrombin monitoring performed with a U.S. FDA-approved device

Reimbursable Codes & Coverage Mapping

Separately reimbursed services - HCPCS/CPT codesmixedCovered

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; includes face-to-face demonstration, obtaining at least one blood sample, 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 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; billing units of service include 4 tests
G0250	Physician review, interpretation, and patient management of home INR testing for patient who meets Medicare coverage criteria; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests
93792	Patient/caregiver training for initiation of home INR monitoring under direction of physician or qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results
93793	Anticoagulation management for a patient taking warfarin; must include review and interpretation of a new home, office, or lab INR test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed

Coverage mapping / benefit coverage notesmixed

G0248 & 93792	Covered under applicable office visit coverage
G0249	Covered under applicable lab coverage
G0250 & 93793	Covered under applicable physician services with no co-payment

Actions, Documentation & Billing Rules

Documentation Required

Demonstration and training documentation (G0248 / 93792)

Provide face-to-face demonstration prior to initiating home INR monitoring, obtain at least one blood sample, instruct on reporting home INR results, and document the patient's or caregiver's ability to perform testing and report results.

Affected codes: G0248, 93792

Billing Rule

Provision of test materials billing units (G0249)

When billing G0249 for provision of testing materials and equipment for home INR monitoring, billing units of service include 4 tests and testing should not occur more frequently than once a week.

Billing units include 4 tests
Testing not more frequently than once a week
Affected code: G0249

Billing Rule

Physician review/management billing units (G0250)

G0250 covers physician review, interpretation, and patient management of home INR testing; billing units include 4 tests and testing should not occur more frequently than once a week.

Billing units include 4 tests
Testing not more frequently than once a week
Affected code: G0250

Billing Rule

Anticoagulation management reporting (93793)

Report 93793 for anticoagulation management when the service includes review and interpretation of a new INR test result (home, office, or lab), patient instructions, dosage adjustment as needed, and scheduling of additional tests when performed.

Report 93793 when review and interpretation of a new INR result is performed
Service must include patient instructions, dosage adjustment (if needed), and scheduling of additional test(s)

Background & Evidence

Background: Home INR monitoring is an alternative to office or laboratory testing for patients on chronic warfarin therapy and uses U.S. FDA-cleared devices (examples: CoaguChek XS, ProTime, and INRatio 2). For effective use, patients require face-to-face training and demonstration, must be able to obtain at least one blood sample and generate INR results comparable to laboratory measures, and must be able to report results to their clinician. Billing and coding guidance specifies demonstration/training codes and provision/management codes with associated requirements (e.g., documentation of patient ability to perform testing and reporting).

Evidence / Source	Details
{"text":"FDA clearance example","status":""},{"text":"CoaguChek XS System cleared for patient self-testing (2007)","status":""}
{"text":"Guideline/evidence sources","status":""},{"text":"Cochrane review and multiple RCTs/meta-analyses cited (e.g., Matchar 2010; Bloomfield 2011; Heneghan 2012)","status":""}

Definitions

Home prothrombin time monitoringPatient self-testing of prothrombin time / INR using an FDA-approved device in the home setting, often combined with self-management or physician-managed dose adjustments.

Name	Number	Type	Effective Date
{"text":"Home PROTHROMBIN Time/INR Monitoring for Anticoagulation Management","status":""},{"text":"190.11","status":""},{"text":"NCD","status":""},{"text":"","status":""}

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Home Prothrombin Time Monitoring

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

Medical Coverage Policy | Home Prothrombin Time Monitoring

Coverage Summary & Scope

Medically Necessary Criteria

Reimbursable Codes & Coverage Mapping

Actions, Documentation & Billing Rules

Background & Evidence

Medicare Coverage Determinations

Revision History