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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 2.5
Home Prothrombin Time (PT) International Normalized Ratio (INR) Monitor
Issue Date:  March 3, 2005
G0248, G0249, G0250
Home PT INR monitoring devices are portable, battery-operated, hand-held analyzing systems designed for testing a small sample of fresh, capillary whole blood obtained by a finger-stick using a lancet device. Depending on the system, the drop of blood is placed on a test strip or disposable reagent cuvette. A new test strip or reagent cartridge must be used with each test performed. Once clotting is initiated, PT is determined by different ways depending on the device:
•  By cessation of blood flow;
•  By changes in light transmission;
•  Through use of fluorescent thrombin substrate.
3.1  Home PT INR monitors may be covered for patients meeting the following criteria:
3.1.1  The patient must have a medical condition requiring lifetime warfarin therapy and monitoring of prothrombin time activity.
3.1.2  The patient must need to have frequent prothrombin time testing once a week or multiple times per month.
3.1.3  The patient (or patient’s caregiver) must have the ability to use the prothrombin time monitoring device after obtaining education on its proper use from an appropriate health care professional.
3.2  The monitor must be prescribed by a physician.
3.3  The device must have U.S. Food and Drug Administration (FDA) approval.
3.4  Related services and supplies, such as PT test strips and office visits, are covered.
3.5  Education or demonstration related to the use of the device is considered incidental to the office visit or the provision of the materials and equipment. Additional reimbursement is not warranted.
Date of FDA approval of the device.
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