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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Health Plan PT Coverage | OpenPayer
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    CurrentProvidence Health PlanPolicy 413

    Prothrombin Time (PT)

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    This Medicare Advantage policy governs coverage and billing of prothrombin time testing for Providence Health Plan, Providence Health Assurance, and Providence Plan Partners, as applicable. Coverage is based on CMS National Coverage Determination 190.17 and the applicable CMS ICD-10 coding policy, with member benefit and Evidence of Coverage terms controlling when they conflict.

    Policy Summary
    PayerProvidence Health Plan
    PolicyProthrombin Time (PT)
    Policy CodePolicy 413
    Change TypeInterim update
    Effective DateOct 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateMay 1, 2027
    Key ActionBill PT services with an ICD-10-CM diagnosis code from the current CMS Lab NCD coding policy and meet all applicable NCD 190.17 requirements.
    SourceLink
    POLICY UPDATE CHANGES

    The October 2026 interim update revised the ICD-10 diagnosis code configuration to align with CMS Change Request 14536 for October 2026.

    Medicare OnlyProduct and benefit application
    CPT 85610Listed covered PT procedure code
    NCD 190.17CMS coverage reference
    No prior authorization

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Prior authorization status for listed services
    CMS ICD-10 list requiredDiagnosis coding condition for potential coverage

    Medicare-Covered Prothrombin Time Testing

    Medicare-covered prothrombin time testing

    Covered when all applicable CMS and plan requirements are met:

    Covered PT testing requirements

    • CMS coverage authority: The service is covered under the applicable Medicare guideline and CMS National Coverage Determination 190.17.NCD 190.17

      CMS guidance governs if it conflicts with this policy.

    • Diagnosis coding: Bill CPT 85610 with an ICD-10-CM diagnosis code included in the most current CMS NCD 190.17 coding policy for the date services were or will be rendered.Current CMS Lab NCD ICD-10 code list

      A diagnosis code appearing on the list does not by itself guarantee coverage.

    • Medical necessity and utilization compliance: Meet all applicable NCD 190.17 criteria, including test-coverage requirements, utilization limitations, and repeat-testing billing instructions.As specified by NCD 190.17

      Utilization may be subject to audit.

    This policy and NCD 190.17 do not address prothrombin time tests involving substitution of plasma fractions when billed under CPT 85611.

    Services or items excluded by Medicare or the member’s Evidence of Coverage are not covered, even when they may appear medically indicated. This includes services that are not medical in nature, are cosmetic, or are not medically reasonable and necessary.

    Services that are not medically reasonable and necessary under Title XVIII of the Social Security Act, Section 1862(a)(1)(A), may be excluded from coverage.

    Diagnosis and NCD Requirements

    Prothrombin time testing with an NCD 190.17 diagnosis code

    CPT 85610 may be covered only when all of the following requirements are met:

    NCD-supported coverage requirements

    • Bill the prothrombin time service with an ICD-10-CM diagnosis code included in the current CMS NCD 190.17 coding policy.Current CMS Lab NCD ICD-10 code list

      Use the code-list version that corresponds to the date services were or will be rendered.

    • Meet all applicable criteria in CMS NCD 190.17, including applicable test-coverage requirements, utilization limitations, and repeat-testing billing instructions.As specified in NCD 190.17
    • Do not rely on inclusion of the diagnosis code alone as evidence of coverage; the diagnosis-code listing does not guarantee automatic coverage.

    Covered and Unaddressed Procedure Codes

    CPTCPTCovered
    85610Prothrombin time
    Not addressed by this policy and NCDCPT
    85611PT tests with substitution of plasma fractions

    Billing, Documentation, and Denial Prevention

    Documentation Required

    NCD-Supported Diagnosis Documentation

    Bill PT services with an ICD-10-CM diagnosis code included in the current CMS Lab NCD Coding Policy Manual and Change Report for NCD 190.17. Select the Lab Code List ICD10 version matching the service date and ensure all applicable NCD requirements are met; a listed diagnosis does not guarantee coverage.

    • Use the current CMS Lab NCD coding policy and applicable Covered Code List version.
    • Locate NCD 190.17 in column A of the applicable Lab Code List ICD10 spreadsheet.
    Documentation Required

    Audit and Utilization Support

    Maintain records supporting medical necessity, compliance with NCD 190.17, applicable test-coverage and utilization limitations, and repeat-testing billing requirements. Services do not require prior authorization, but claims may be subject to audit and all NCD criteria must be met.

    • Retain documentation supporting medical necessity and NCD compliance.
    • Follow applicable utilization limits and repeat-testing billing instructions.

    Utilization and Repeat-Testing Requirements

    Frequency Limits
    Utilization limitationsApplicable utilization limitations under NCD 190.17 apply.
    Repeat testingFollow the repeat-testing billing instructions in the applicable NCD 190.17.
    AuditUtilization may be subject to audit, and all NCD 190.17 criteria must be met.
    Prior authorizationProthrombin time testing does not require prior authorization.
    Policy Summary
    PayerProvidence Health Plan
    PolicyProthrombin Time (PT)
    Policy CodePolicy 413
    Change TypeInterim update
    Effective DateOct 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateMay 1, 2027
    Key ActionBill PT services with an ICD-10-CM diagnosis code from the current CMS Lab NCD coding policy and meet all applicable NCD 190.17 requirements.
    SourceLink
    On This Page
    Medicare-Covered Prothrombin Time TestingDiagnosis and NCD RequirementsCovered and Unaddressed Procedure CodesBilling, Documentation, and Denial PreventionUtilization and Repeat-Testing Requirements
    Denial Risk

    NCD Criteria or Diagnosis Requirements Not Met

    CPT 85610 may be denied when it is not billed with a diagnosis code included in the current CMS NCD 190.17 coding policy or when other NCD requirements are not met. Inclusion of an ICD-10-CM code on the list does not automatically establish coverage.

    • Verify the diagnosis code against the current CMS NCD 190.17 coding policy.
    • Confirm that all applicable NCD criteria and medical-necessity requirements are satisfied.
    Denial Risk

    Unlisted Code Submission

    All unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing. An unlisted code submitted for a non-covered service addressed by this policy will be denied as not covered; for a potentially covered service, prior authorization is recommended to help avoid a post-service denial.

    • Non-covered service: claim-level denial as not covered.
    • Potentially covered service: obtain prior authorization when possible before submission.
    Billing Rule

    NCCI or MUE Edit

    HCPCS and CPT codes may be subject to CMS National Correct Coding Initiative procedure-to-procedure (PTP) bundling edits and daily maximum edits known as medically unlikely edits (MUEs). This policy does not take precedence over NCCI edits or MUEs.

    • Review applicable CMS coding guidelines and NCCI code combinations.
    • Check daily unit limits and address applicable MUEs before billing.