College of American Pathologists

  Autologous, apheresis services:
  coding for payment


Reprinted from June 1993 CAP TODAY

Carl Graziano

The pathologist plays an important role in the evaluation and management of patients who are undergoing autologous blood transfusions and therapeutic apheresis, thereby providing services that, properly coded, should qualify for reimbursement from insurers.

Autologous blood transfusion is not new; reports of the procedure date to 1921. But the use of autologous transfusions grew rapidly in the past two decades.

“The advantage of the autologous transfusion is the patient gets back his own blood, so he doesn't need to be afraid he'll catch hepatitis or AIDS,” said Hans Peters, MD, a College member at St. Francis Hospital in Columbus, Ga. , and an adviser to the College's Transfusion Medicine Resource Committee. “Autologous transfusion has more or less come into vogue with the advent of the AIDS problem. Prior to that, autologous transfusion was rarely, if ever, used.”

Dr. Peters pointed to the importance of the pathologist’s early involvement in the management of an autologous donor.

“ln our practice, we would treat the patient who also is an autologous donor essentially as a patient who comes to make a donation of blood,” he said. “In other words, we would use the same history for review of systems and the same physical examination, hemoglobin and hematocrit determinations as we would for an ordinary donor.”

“Further, we would take additional history and perform physical examinations as is appropriate to the patient’s condition. This includes, of course, taking blood pressure, temperature. Then you discuss with the patient what your findings are and you set up a [donation] program appropriate to the patient’s health status.”

Similar early and ongoing involvement by a pathologist is necessary for apheresis patients, Dr. Peters said. In apheresis, a patient’s blood is removed, component parts such as plasma and leukocytes are separated from it, and the remaining components are then returned.

The performance of therapeutic apheresis activities, as with autologous transfusions, requires close coordination between the patient’s primary physician and the transfusion medicine physician--typically a pathologist--responsible for carrying out the procedure, said Roslyn Yomtovian, MD, of the Department of Pathology at University Hospitals of Cleveland, Ohio.

Indeed, the American Association of Blood Banks Standards for Blood Banks and Transfusion Services indicates the physician responsible for the therapeutic apheresis service is not only primarily responsible for determining whether the procedure will be done but also is charged with the evaluation and management of the patient throughout the procedure, Dr. Yomtovian said. “In this capacity, the blood bank physician is a highly trained, clinical specialist who orchestrates the application of apheresis technology--plasma exchange or cytapheresis--to clinical patient care,” she said.

In this role, the blood bank physician is at the patient's bedside to conduct a clinical examination; to write the consult note, clinical orders, and daily progress notes; and to manage those aspects of clinical care necessary for therapeutic apheresis. The time required for these clinical tasks varies with the indication for the procedure and the medical stability of the patient.

In medically unstable patients, such as those with thrombotic thrombocytopenic purpura, acute severe Guillain-Barre syndrome, or acute leukemia, therapeutic apheresis often will require additional medical management of the recipients for fluid balance and transfusional needs, Dr. Yomtovian said. In these patients, the blood bank physician not only coordinates with other members of the clinical management team, but also is a frontline participant with this team in providing clinical care, she said.

With autologous donors, who typically are older than volunteer allogeneic donors and often exhibit medical conditions that would disqualify them from allogeneic donation, it is common for the pathologist to be involved in determining their medical eligibility and clinical management, Dr. Yomtovian said.

“Frequent eligibility concerns in autologous donors that require a pathologist's input relate to cardiac history and arrhythmias, and concurrent medications, especially antibiotics,” she said. “In some instances, the pathologist consults with the primary care physician or appropriate specialist to assess the efficacy and timing of the autologous phlebotomies.”

Special assessments that involve a pathologist include deciding to volume replace an autologous donor with normal saline after phlebotomy, evaluating the need for recombinant erythropoietin, the “leap-frogging” of units nearing their expiration dates, and freezing autologous blood. The pathologist working as a consultant to the surgeon also might manage alternative autologous transfusion strategies, such as perioperative hemodilution, intraoperative blood collection, and postoperative blood salvage, Dr. Yomtovian said.

These evaluation and management services, she added, are in addition to the pathologist's traditional role in “developing and carrying out policies and procedures, and overseeing the ongoing performance of these activities.”

At the Stormont-Vail Regional Medical Center in Topeka, Kan., the pathologists of Topeka Pathology Group, PA, head the center’s therapeutic plasmapheresis service, and patient care mostly follows two basic scenarios, said Mark S. Synovec, MD, a College member and associate pathologist with TPG.

One common scenario involves a critically ill patient referred to the pathologists by a primary care physician for possible plasmapheresis, Dr. Synovec said. The service typically involves a variably intense chart review, a review of systems and appropriate history, and a physical examination, with a consultation report to the primary care team-services codable under the Current Procedural Terminology as an Dr. Synovec inpatient consultation, or 99252. Depending on the pathologist's recommendation, regular plasmapheresis will begin. The appropriate code for apheresis is 36520. Subsequent follow-up and evaluation independent of apheresis also may be indicated; here, the pathologist may use an inpatient consultation code of 99261.

Another scenario could involve an established patient with a chronic disease requiring periodic plasmapheresis, such as chronic inflammatory polyneuropathy. “In this case, we admit the patient to the outpatient center for the day, and briefly evaluate the patient to determine if the procedure can be safely performed. We are then responsible for writing orders as well as writing admitting, procedure, and discharge notes,” Dr. Synovec said. The pathologist may use an established outpatient visit CPT code, such as 99212, as well as the procedure code for plasmapheresis, 36520.

“These activities are recognized as physician services in CPT ’93, and all payers should recognize these services for payment,” said Paul A. Raslavicus, MD, chair of the College's Council on Government and Professional Affairs and chief pathologist at New England Memorial Hospital in Stoneham, Mass.

In many cases of autologous donations, he said, an asymptomatic patient about to undergo elective surgery and for whom no problem-pertinent systems review is needed would qualify for services at the lowest level, code 99201. But in other cases, an expanded problem-focused history, systems review, and examination would be performed-characteristic of evaluation and management services at the second level of complexity, code 99202. The more difficult patient, or one who develops complications from the donation, would be coded at 99203 or, sometimes, 99204, Dr. Raslavicus said.

“On repeat donations by the same patient,” he said, “the patient may use lesser amounts of physician input, and in those cases the lowest level of established patient code--99211--would characterize the physician service.”

CPT evaluation and management codes include typical times and examples of patient-specific clinical problems that, although not blood service-specific, provide pathologists with guidance on which coding to use for autologous or apheresis services.

“Pathologists who provide evaluation and management services to autologous or apheresis patients should consult CPT for the correct codes to use—for outpatient or inpatient evaluation and management services,” Dr. Raslavicus advised.