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Laboratory Fee Schedule

2019
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CMS Transmittals



National Coverage Determination
Procedure Code: G0249
Home Prothrombin Time INR Monitoring for Anticoagulation Management
CMS Policy Number: 190.11
Back to NCD List



To review all requirements of this policy, please see: CMS NCD listing by Chapter

Covered ICD-10 Codes.

ICD-10Descriptor
D68.51 Activated protein C resistance
D68.52 Prothrombin gene mutation
D68.59 Other primary thrombophilia
D68.61 Antiphospholipid syndrome
D68.62 Lupus anticoagulant syndrome
I23.6 Thombos of atrium/auric append/ventr as current comp fol AMI
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.90 Septic pulmonary embolism without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
I27.24 Chronic thromboembolic pulmonary hypertension
I27.82 Chronic pulmonary embolism
I48.0 Paroxysmal atrial fibrillation
I48.1 Persistent atrial fibrillation
I48.2 Chronic atrial fibrillation
I67.6 Nonpyogenic thrombosis of intracranial venous system
I80.11 Phlebitis and thrombophlebitis of right femoral vein
I80.12 Phlebitis and thrombophlebitis of left femoral vein
I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral
I80.211 Phlebitis and thrombophlebitis of right iliac vein
I80.212 Phlebitis and thrombophlebitis of left iliac vein
I80.213 Phlebitis and thrombophlebitis of iliac vein, bilateral
I80.221 Phlebitis and thrombophlebitis of right popliteal vein
I80.222 Phlebitis and thrombophlebitis of left popliteal vein
I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral
I80.231 Phlebitis and thrombophlebitis of right tibial vein
I80.232 Phlebitis and thrombophlebitis of left tibial vein
I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.291 Phlebitis and thombophlb of deep vessels of r low extrem
I80.292 Phlebitis and thombophlb of deep vessels of l low extrem
I80.293 Phlebitis and thombophlb of deep vessels of low extrm, bi
I82.0 Budd-Chiari syndrome
I82.210 Acute embolism and thrombosis of superior vena cava
I82.211 Chronic embolism and thrombosis of superior vena cava
I82.220 Acute embolism and thrombosis of inferior vena cava
I82.221 Chronic embolism and thrombosis of inferior vena cava
I82.290 Acute embolism and thrombosis of other thoracic veins
I82.291 Chronic embolism and thrombosis of other thoracic veins
I82.3 Embolism and thrombosis of renal vein
I82.411 Acute embolism and thrombosis of right femoral vein
I82.412 Acute embolism and thrombosis of left femoral vein
I82.413 Acute embolism and thrombosis of femoral vein, bilateral
I82.421 Acute embolism and thrombosis of right iliac vein
I82.422 Acute embolism and thrombosis of left iliac vein
I82.423 Acute embolism and thrombosis of iliac vein, bilateral
I82.431 Acute embolism and thrombosis of right popliteal vein
I82.432 Acute embolism and thrombosis of left popliteal vein
I82.433 Acute embolism and thrombosis of popliteal vein, bilateral
I82.441 Acute embolism and thrombosis of right tibial vein
I82.442 Acute embolism and thrombosis of left tibial vein
I82.443 Acute embolism and thrombosis of tibial vein, bilateral
I82.491 Acute embolism and thrombosis of deep vein of r low extrem
I82.492 Acute embolism and thrombosis of deep vein of l low extrem
I82.493 Acute embolism and thombos of deep vein of low extrm, bi
I82.511 Chronic embolism and thrombosis of right femoral vein
I82.512 Chronic embolism and thrombosis of left femoral vein
I82.513 Chronic embolism and thrombosis of femoral vein, bilateral
I82.521 Chronic embolism and thrombosis of right iliac vein
I82.522 Chronic embolism and thrombosis of left iliac vein
I82.523 Chronic embolism and thrombosis of iliac vein, bilateral
I82.531 Chronic embolism and thrombosis of right popliteal vein
I82.532 Chronic embolism and thrombosis of left popliteal vein
I82.533 Chronic embolism and thrombosis of popliteal vein, bilateral
I82.541 Chronic embolism and thrombosis of right tibial vein
I82.542 Chronic embolism and thrombosis of left tibial vein
I82.543 Chronic embolism and thrombosis of tibial vein, bilateral
I82.591 Chronic embolism and thrombosis of deep vein of r low extrem
I82.592 Chronic embolism and thrombosis of deep vein of l low extrem
I82.593 Chronic embolism and thombos of deep vein of low extrm, bi
I82.621 Acute embolism and thrombosis of deep veins of r up extrem
I82.622 Acute embolism and thrombosis of deep veins of l up extrem
I82.623 Acute embolism and thombos of deep veins of up extrem, bi
I82.721 Chronic embolism and thrombosis of deep veins of r up extrem
I82.722 Chronic embolism and thrombosis of deep veins of l up extrem
I82.723 Chronic embolism and thombos of deep veins of up extrem, bi
I82.890 Acute embolism and thrombosis of other specified veins
I82.891 Chronic embolism and thrombosis of other specified veins
I82.A11 Acute embolism and thrombosis of right axillary vein
I82.A12 Acute embolism and thrombosis of left axillary vein
I82.A13 Acute embolism and thrombosis of axillary vein, bilateral
I82.A21 Chronic embolism and thrombosis of right axillary vein
I82.A22 Chronic embolism and thrombosis of left axillary vein
I82.A23 Chronic embolism and thrombosis of axillary vein, bilateral
I82.B11 Acute embolism and thrombosis of right subclavian vein
I82.B12 Acute embolism and thrombosis of left subclavian vein
I82.B13 Acute embolism and thrombosis of subclavian vein, bilateral
I82.B21 Chronic embolism and thrombosis of right subclavian vein
I82.B22 Chronic embolism and thrombosis of left subclavian vein
I82.B23 Chronic embolism and thrombosis of subclav vein, bilateral
I82.C11 Acute embolism and thrombosis of right internal jugular vein
I82.C12 Acute embolism and thrombosis of left internal jugular vein
I82.C13 Acute embolism and thrombosis of int jugular vein, bilateral
I82.C21 Chronic embolism and thrombosis of r int jugular vein
I82.C22 Chronic embolism and thrombosis of l int jugular vein
I82.C23 Chronic embolism and thombos of int jugular vein, bilateral
O87.3 Cerebral venous thrombosis in the puerperium
Z79.01 Long term (current) use of anticoagulants
Z86.718 Personal history of other venous thrombosis and embolism
Z95.2 Presence of prosthetic heart valve

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