| 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. |
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