Medical Policy

Effective Date:02/04/2009 Title:Home Anticoagulation Monitors
Revision Date:03/01/2017 Document:BI108:00
CPT Code(s):G0248-G0250
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Home INR/Prothrombin time monitors and all supplies are covered under the DME benefit. 

2)    This benefit is only available to patients who are expected to require life-long INR monitoring because of long-term/permanent use of Warfarin.

Medical Statement

1)    ALL of the following requirements must be met:

a)    The monitor and the home testing must be prescribed by a treating network physician, and received from a network DME provider; and

b)    The patient must have a face-to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to home use; and

c)     The patient must have been taking warfarin therapy and been stable for at least three months prior to using the home testing device; and

d)    The patient’s medical condition must not require testing more than once a week; and

e)    The patient must have a medical condition that is expected to require lifelong monitoring with diagnosis code Z79.01 (Long-term [current] use of anticoagulants).  A patient expected to be on warfarin for a defined time (for example, after a single episode of DVT due to specific limited risk factors) is not eligible for coverage.

2)    While home INR testing using devices such as CoaguChek has been shown to be as accurate as that provided in a laboratory, it has not been shown to produce better clinical outcomes or decreased complications as opposed to monitoring of INR in a coagulation clinic.

Codes Used In This BI:


Demonstrate use home INR mon


Provide INR test mater/equip


MD INR test revie inter mgmt.


1)    Demonstration of use of home INR monitoring is limited to once per lifetime.

2)    Billing for supplies and equipment, and for review of results, is limited to once per 28 days.



1.     Effective 03/01/2017:  Added ICD10 diagnosis code Z79.01, Long-term (current) use of anticoagulants to BI as a requirement for coverage.

Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.