Oncology & Hematology Coding Alert

Therapeutic phlebotomy is most often associated with the hematology side of oncology practices. But coders sometimes confuse the procedure with blood draws that are common in follow-up care for chemotherapy. And coding the wrong service in the wrong situation will probably lead to denials.

And with $57.60 at stake for 99195 (Phlebotomy, therapeutic [separate procedure]) in 2008, denials can be costly. That's 1.52 transitional non-facility RVUs, using the 2008 Medicare Physician Fee Schedule, multiplied by conversion factor 37.8975.

Here's how to conquer coding confusion between phlebotomies and blood draws.

Your colleagues may use the word "phlebotomy" to refer to a blood draw for testing purposes, but be careful -- you should only use code 99195 to describe therapeutic phlebotomy, says Janae Ballard, CPC-EM, ACS-EM, revenue coding analyst at the Virginia Mason Medical Center in Seattle.

What's the difference? "Code 99195 represents a therapeutic phlebotomy, often used in the treatment of polycythemia vera [ICD-9 code 238.4] to reduce the hematocrit and red blood cell mass. Therapeutic phlebotomies are used in the treatment of other diseases as well," according to the June 1996 CPT Assistant.

Sometimes known as "therapeutic bleeding," the procedure involves "a controlled removal of a large volume (usually a pint or more) of blood," according to Aetna's clinical policy bulletin on therapeutic phlebotomy. "It is used mainly to reduce blood volume, red cell mass and iron stores."

So, your payers will likely be looking for a specific diagnosis from a list of ICD-9 codes that support medical necessity for the phlebotomy procedure. Blue Cross and Blue Shield of Montana's list of acceptable diagnosis codes includes:

- 238.4 -- Polycythemia vera

- 238.7x -- Neoplasm of uncertain behavior of other and unspecified sites and tissues; other lymphatic and hematopoietic tissues

- 275.0 -- Disorders of iron metabolism

- 277.1 -- Disorders of porphyrin metabolism

- 285.0 -- Sideroblastic anemia

- 289.0 -- Polycythemia, secondary.

Caution: Different payers will have different criteria. Be sure to check with the individual payers for their own lists of diagnoses supporting medical necessity.

A physician does not have to perform the procedure and may bill for an office-performed therapeutic phlebotomy by a midlevel provider as "incident-to" his professional services, as long as it was performed under physician supervision and he can show active management of the patient's treatment.

If therapeutic phlebotomy is performed in an inpatient or outpatient setting, the hospital should bill it because the hospital provides the space, personnel and equipment.

Documentation: To further prove medical necessity, the record must include documentation describing the condition being treated, the procedure for each date of service, and the pre-phlebotomy hematocrit (HCT) of greater than 60 percent or red blood cell (RBC) mass.

Physicians should ensure that these results are included in the record so coders can accurately report what was performed and can defend the claim in the event of a denial.

Hidden trap: Fluid infusions are usually necessary for phlebotomy patients to replace the fluid the oncologist or hematologist removes. But although there is not an official Correct Coding Initiative (CCI) edit bundling 90760 (Intravenous infusion, hydration; initial, up to 1 hour) with 99195, your carrier may still deny hydration services reported separately along with phlebotomy.

The reason? Standards of practice. "My understanding of therapeutic phlebotomy is that the fluid used to replace volume loss resulting from the removal of blood is part of the procedure, rather than separate hydration," says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and past-president of the American Academy of Professional Coders National Advisory Board.

You can find further guidance in Chapter XI of the National Correct Coding Initiative Policy Manual for Medicare Services. "Therapeutic phlebotomy services - are not to be reported with transfusion service codes (e.g., CPT codes 86890, 86891), plasmapheresis codes or exchange transfusion codes. Services necessary to perform the phlebotomy (e.g., CPT codes 36000, 36410, 90760-90775) are included in the procedure."

CCI does specifically bundle codes 36000 (Introduction of needle or intracatheter, vein), 36405 (Venipuncture, younger than age 3 years, necessitating physician's skill, not to be used for routine venipuncture; scalp vein), 36420 (Venipuncture, cutdown; younger than age 1 year) and 36425 (- age 1 or over) into code 99195.

Note: For more information on coding for blood draws, see "Watch for These Clues to Use 36415, 8500x for In-House CBC" on page 20.