Oncology & Hematology Coding Alert

A patient has blood drawn at an oncology-hematology practice for routine diagnostic or chemotherapeutic follow-up tests. While this can generally be referred to as a phlebotomy, it should not be coded as 99195 (phlebotomy, therapeutic [separate procedure]). Knowing this can save oncology practices the time and hassle of having to resubmit a denied claim.

While 99195 is for a procedure that requires blood to be drawn, a therapeutic phlebotomy is designed to address specific blood-related maladies, such as polycythemia vera, 238.4, a hematopoietic stem cell disorder characterized by sustained abnormal elevation in the number of red blood cells. Therapeutic phlebotomy is most often associated with the hematology side of oncology practices, but can easily be confused with blood draws that are common in follow-up care for chemotherapy. It is easy to misunderstand the word phlebotomy and apply it to include all blood draws, says Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant based in New Orleans.

Coding for Routine Blood Draws

Rather than coding routine blood draws as 99195, practices should use either 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]) bundled within an evaluation and management (E/M) code, 99211-99215, or a laboratory test code, such as 85022 (hemogram, automated, and manual differential WBC count [CBC]). This will ensure their coding practice for blood draws complies with Medicare regulations.

Coders should determine the nature of the phlebotomy before assigning a procedure code, says Alice G. Ettinger, RN, MSN, CPNP, program coordinator for the division of pediatric hematology and oncology at St. Peters University Hospital in New Brunswick, N.J.

How a practice codes for routine blood draws depends largely on whether it has its own laboratory, sends the specimen to an outside source, or if patients are sent to another place. Below are common coding scenarios:

Outside lab for both blood draw and testing. If the practice sends its patients outside for drawing blood and testing, it cannot bill for either procedure. If a physician did not extract the specimen from the patient, payment will not be allowed. However, if the test was ordered during a visit related to chemotherapy treatment, the practice may be able to code the appropriate E/M service that describes the follow-up visit.

Collect specimen for testing at outside lab. Although testing is done by an outside laboratory, practices can still bill for the blood draw, says Ettinger. Local medical review policies also say that separate charges made by physicians, independent, or hospital laboratories for drawing or collecting specimens should be allowed whether or not the specimens are referred to doctors or other laboratories.

Most Medicare carriers allow for one collection fee for each patient encounter, regardless of the number of specimens drawn. When a series of specimens is required to complete a single test, such as glucose tolerance, 82951 and 82952, the collections should be treated as a single encounter. Therefore, practices should use 36415 once per encounter, while the laboratory is responsible for billing 82951 and 82952. Practices, however, should check with their individual payers on whether to use 36415 when it is part of a larger E/M visit. Some carriers may not allow it to be billed separately. Instead, the blood draw should be bundled as part of the E/M service related to chemo-therapy treatment.

Both collection and testing done in the office. If the practice has its own laboratory to perform blood tests, such as a complete blood count, 85022-85025, the proper way to code is to bundle the draw with the test. So, rather than billing both 36415 and 85022, oncology practices with testing facilities should bill only 85022.

Coding Therapeutic Phlebotomies

Unlike routine blood draws, a phlebotomy is the controlled removal of a large volume of blood to reduce red cell mass and iron stores.

To get paid for this, practices must list one of a limited number of diagnosis codes that Medicare regulations say prove medical necessity. They include:

238.4 polycythemia vera;
238.7 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

Cancer diagnosis codes, which commonly accompany blood draws for chemotherapy treatment, are not acceptable here because there isnt a form of cancer that calls for this kind of treatment, Hickey says. Further, Medicare rules state that use of this procedure for venipuncture or blood drawings is not considered to be reasonable and necessary because a phlebotomy is a completely different procedure; it is designed to relieve specific conditions, while a blood draw requires a small amount of blood for testing.

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 or her professional services as long as it was performed under physician supervision and he or she can show active management of the patients treatment. If it is performed in an inpatient or outpatient setting, it should be billed by the hospital because it provides the space, personnel and equipment.

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 be successfully defended in the event of a denial.