Managed Care - October 2008 - (Page OA4) TABLE 2 Patient self-testing (PST) reimbursement* CPT code Description Option A Option B Option C • Practitioner reviews INR results • Practitioner provides one-time device training • Practitioner leases device to patient • Practitioner provides testing supplies $9.08 $191.20 $140.54/month $118.04 + $191.20 $309.24 $1,804.52 + $191.20 $1,995.72 • Practitioner reviews • Practitioner reINR results only views INR results • Third party provides • Practitioner prodevice training vides one-time de• Third party provides vice training INR device and test- • Third party proing supplies vides device and testing supplies G-0250 G-0248 G-0249 Practitioner review of each set of 4 PST results One-time training on device operation Leasing of device and provision of testing supplies $9.08 $9.08 $191.20 Total yearlya per patient + one-time initial training $118.04 Total yearly per patient, first year of PST a $118.04 *In addition to comprehensive management, according to practitioner options for device ownership, patient training, provision of devices, and distribution of testing supplies. a 1 year includes 13 sets of four (once-weekly) patient self-testing results. INR=international normalized ratio. Source: CMS 2008 Cost-effectiveness The benefits that have been demonstrated by the addition of PST to the usual care model include greater time in therapeutic range, fewer dose changes, reduced risk of bleeding and thrombotic complications, improved survival, and improved quality of life for patients (Ansell 1995, Ansell 2005, Sawicki 1989, Koertke 2007). In addition, several studies have determined that there are significant cost savings for the health care system associated with the decreased incidence of adverse events related to warfarin therapy. Lafata (2000) calculated a cost-effectiveness ratio of $24,818 per avoided adverse event with PST, compared with anticoagulation clinic management alone. This figure, which reflects costs for the year 1997, includes all direct medical costs and patient and caregiver costs related to PST and utilization of care that would be required for treatment of a hemorrhagic or thrombotic event. In a long-term follow-up of the effects of PST, Ansell (1995) determined that patients who self-tested required 50 percent fewer dose adjustments compared with patients in the control group. Both the increased time in therapeutic range and the decrease in required dose adjustments were statistically significant (both P<.001). In addition to the efficacy and safety implications of PST, there may be an advantage for practition- ers in terms of less time and effort required to manage patients who achieve tighter INR control through PST. Practical guidelines for implementation of PST The CMS criteria and the panel’s recommendations provide general guidance for implementing PST. The panel recognizes there is no one correct way to incorporate PST into a medical practice. Similar to recommendations for management of other diseases, there are many acceptable ways for guidelines to be implemented in the day-to-day delivery of primary care, allowing practitioners the flexibility to develop individualized protocols and procedures that function best in their particular settings. Patient selection Selection of appropriate candidates is an important part of successful implementation of PST in a medical practice. A wide range of patients may be appropriate candidates for PST, including those with risk factors for major or fatal bleeding, such as high intensity of anticoagulation; age 65 or older; highly variable INRs; or a history of GI bleeding, hypertension, cerebrovascular disease, serious heart disease, anemia, malignancy, trauma, renal insufficiency, concomitant drugs, and the need for long- 4 MANAGED CARE / SUPPLEMENT
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