Pathology/Lab Coding Alert

Usually, the pathologist responsible for apheresis services also provides evaluation and management (E/M) of the patient before and during the procedure. Some of these services are bundled, but others should qualify for reimbursement if properly coded, states Catherine Saporito, MT (ASCP), SBB, blood bank manager at University of Illinois Hospital in Chicago.

Apheresis is the process of removing a patients blood, separating out components such as plasma, leukocytes or stem cells, and returning the remainder. Typically, a pathologist specializing in transfusion medicine carries out the process, working in close coordination with the patients primary care physician (PCP). It is often the blood bank physician who evaluates and monitors the patient before, during and after the apheresis procedure, says Saporito. This might include a review of patient history, physical examination, and writing clinical orders, progress notes, a consultation report and discharge directions. The work involved in these tasks varies based on the indication for the procedure and the patients condition.

Adsorption Column and Stem Cell Apheresis

A new apheresis code in CPT 2000 describes the process of passing the blood through an adsorption column during apheresis. For example, a Pro-Sorba adsorption column may be used during a three-month course of repeat plasmapheresis to remove certain factors from the blood of a rheumatoid arthritis patient (714), says James W. Smith, MD, Ph.D., associate medical director of the Oklahoma Blood Institute, a blood center for transfusion medicine and volunteer donors. In this case, code 36521 (therapeutic apheresis; with extracorporeal affinity column adsorption and plasma reinfusion) would be reported. Because this procedure is repeated weekly, probably a venous access device would be instated to provide ease of access at subsequent visits, says Smith. The appropriate CPT code for venous access, such as 36533 (insertion of implantable venous access device, with or without subcutaneous reservoir), would be used to report that service separately from the apheresis service. When the apheresis treatments are complete, the appropriate device removal code, such as 36535 (removal of implantable venous access device), would be reported.

A similar scenario would exist for a patient with unresponsive hyperlipidemia [272.4], states Smith. A patient with uncontrollable LDL cholesterol may require plasmapheresis using an adsorption column as often as twice a week to keep his or her cholesterol level in check. Again, code 36521 would be used to report this service.

Non-Hodgkins lymphoma (202.8) also may require repeated apheresis, but in this case its for stem cell collection, says Smith. CPT provides a separate code for this apheresis and cell accumulation procedure: 38231 (blood derived peripheral stem cell harvesting for transplantation, per collection).

In this case, the patient would undergo multiple procedures until adequate stem cells have been collected for reinfusion, says Smith. In addition to reporting 38231 for each collection, codes for vascular access, administration of growth factor (90782 for subcutaneous injection), cryopreservation of cells (86890, collection processing and storage; predeposited; and 86930, frozen blood, preparation for freezing, each unit), and infusion of stem cells (38240-38241) may be reported when those services are provided during the course of treatment.

When pathologists provide additional evaluation and management or other services to apheresis patients, they can report those services using the appropriate CPT codes, subject to specific payer restrictions, concludes Smith.

How to Use the Codes

A hospital patient with acute Guillain-Barre syndrome (357.0) might be referred for plasmapheresis to remove antibodies involved in the disease. Code 36520 (therapeutic apheresis; plasma and/or cell exchange) would be correct for the service.

But certain E/M services would also be provided by the blood bank physician for the initial assessment of the patient, says Smith. The physician, usually a pathologist, would evaluate and report on the patients history and current physical condition to determine whether the procedure is indicated. If these services are provided, code one of the initial inpatient consultation codes (99251-99255), depending on the amount of time spent with the patient and the complexity of the medical decision-making involved.

Note: If those services are provided by the pathologist and if the patient was not already a hospital patient but was being admitted to the hospital for the procedure, the initial hospital care codes (99221-99223) should be used instead.

During the apheresis procedure, the pathologist would write procedure notes, monitor parameters such as plasma flow, fluid replacement and anticoagulation, and be available to intervene in the event of complications, says Smith. These services are bundled into the apheresis service provided on that day and should not be reported as subsequent hospital care (99231-99233). In fact, there is a Correct Coding Initiative (CCI) edit that denies payment of these codes when reported with 36520 on the same day.

If any additional procedures are carried out in association with the apheresis service, such as the insertion of a vascular access device, many payers will allow those to be reported individually. Different practitioners may be involved in vascular access, depending on the procedure, states Smith. For example, a surgeon may implant a central line for repeated apheresis service. The selection of the type of access device will depend on the patients circumstances, but the codes for the various vascular access procedures are found within the range of 36000-36861. These should be reported by the physician supplying the service, says Smith.

Replacement fluids would also be billed separately, but these are not reported using CPT codes, since they essentially represent supplies, not services, states Smith. Finally, a hospital discharge code (99238-99239) can be reported with therapeutic apheresis (36520) when the blood bank physician provides these services. As always, check with your individual payers to confirm what additional services can be reported with apheresis, concludes Smith.

In a different scenario, a patient with sickle-cell anemia (282.6) who is scheduled for surgery may first be referred as an outpatient for replacement transfusion, says Saporito. In this procedure, hemoglobin S concentration is reduced and hemoglobin A elevated through apheresis (36520), she continues. To report the physician consultation service involved in taking patient history, conducting examination and determining appropriateness of the procedure, the blood bank physician could report one of the codes 99241-99245 (office consultation), depending on the time and complexity involved.

Note: A CCI edit denies the use of E/M codes 99211-99215 (office or other outpatient visit) on the same day that apheresis (36520) is coded for that patient.