Therapeutic Phlebotomy: Insurance Coding

Therapeutic phlebotomy is a medical procedure in which a large volume of blood is removed from the body to treat certain blood disorders. It is performed by a specialist known as a therapeutic phlebotomist under controlled circumstances. The procedure is used to reduce an excessively high number of red blood cells or excessively high levels of iron in the blood. The conditions under which therapeutic phlebotomy is considered medically necessary by insurance companies include erythrocytosis of undetermined aetiology, haemochromatosis, individuals receiving testosterone therapy, non-alcoholic fatty liver disease with hyperferritinaemia, polycythaemia vera, porphyria cutanea tarda, and sickle cell disease.

Polycythemia vera

The most common treatment for polycythemia vera is therapeutic phlebotomy, a procedure that removes excess blood from the body. This treatment is done frequently at first, such as weekly, and then less often once enough blood has been removed to reduce the body's iron stores. Therapeutic phlebotomy is considered medically necessary by insurance providers for polycythemia vera, as it helps to reduce the risk of complications and ease symptoms.

The procedure code for therapeutic phlebotomy is 99195, and it falls under the category of "Other Medicine Services and Procedures" in the Current Procedural Terminology (CPT®) coding system. This code specifically refers to the removal of venous blood to reduce the number of red blood cells or treat high levels of iron or potassium in the blood.

In addition to therapeutic phlebotomy, other treatments for polycythemia vera include certain medications such as chemotherapy drugs and selective serotonin reuptake inhibitors (SSRIs). It is important for patients to work with their healthcare providers to create a treatment plan that fits their individual needs and helps manage their symptoms.

Polycythemia secondary to cyanotic congenital heart disease

The current clinical practice for treating polycythemia secondary to CCHD is to perform therapeutic phlebotomy to reduce the hematocrit to below 65%. Phlebotomy involves the removal of a large volume of blood, usually a pint or more, primarily to reduce red blood cell mass and iron stores. In the context of polycythemia secondary to CCHD, therapeutic phlebotomy is used to lower the hematocrit and reduce symptoms related to hyperviscosity.

However, it is important to note that dehydration and iron deficiency can also precipitate or aggravate hyperviscosity symptoms. Therefore, it is recommended to correct dehydration and iron deficiency before considering phlebotomy in patients with CCHD and a hematocrit above 65%. Additionally, phlebotomy is generally discouraged unless the patient is symptomatic, and other management strategies, such as volume replacement with intravenous fluids, should be considered first.

In terms of insurance codes, therapeutic phlebotomy is considered a medically necessary procedure and is eligible for coverage under specific codes. For example, the CPT code 99195 is used for therapeutic phlebotomy, and it involves the removal of venous blood to reduce red blood cells or treat high levels of iron or potassium in the blood.

Hemochromatosis

Therapeutic phlebotomy is a medical procedure that treats hemochromatosis by removing excess iron from the body. It involves the same process as blood donation, but the frequency of the procedure depends on the patient's condition and can be much higher than the typical rate of blood donation. The procedure is performed by a phlebotomist in a medical setting, such as a hospital or physician's office, and typically takes 10-15 minutes to complete. It is considered safe and effective for treating hemochromatosis.

During therapeutic phlebotomy for hemochromatosis, a technician removes approximately 450-500 milliliters (about one pint) of blood. This amount of blood removal is significant and helps reduce iron overload. The frequency of therapeutic phlebotomy depends on the patient's lab tests, genotype, symptoms, and overall health. The treatment is continued until the patient's ferritin level, a measure of blood iron levels, reaches the goal set by their physician. Typically, each phlebotomy session reduces ferritin levels by 30-50 points.

Once the patient's iron levels are normalized, the focus shifts to maintaining healthy iron and ferritin levels. At this stage, individuals with hemochromatosis can often maintain their iron levels by donating blood at community blood donation centers. However, not all blood centers accept blood donations from people with hemochromatosis, and a physician's prescription may be required for more frequent phlebotomy.

Therapeutic phlebotomy is an essential part of hemochromatosis treatment and can help alleviate symptoms and prevent further damage caused by excess iron accumulation.

Porphyria cutanea tarda

Types

PCT has two main types:

• Type 1: Acquired or sporadic (75% to 80% of cases)
• Type 2: Hereditary or familial (20% to 25% of cases)

There is also a rare type 3, which accounts for <1% of cases.

Symptoms

Patients with PCT present with fragile skin, mainly on sun-exposed areas. Phototoxicity is delayed, thus patients do not always connect sun exposure with symptoms. Spontaneously or after minor trauma, tense bullae develop. Some bullae are hemorrhagic. Accompanying erosions and ulcers may develop secondary infection; they heal slowly, leaving atrophic scars. Sun exposure occasionally leads to erythema, edema, or itching.

Diagnosis

In otherwise healthy patients, fragile skin and blister formation suggest PCT. Although all porphyrias that cause skin lesions are accompanied by elevated plasma porphyrins, elevated urinary uroporphyrin and heptacarboxyl porphyrin, and fecal isocoproporphyrin indicate PCT. Urine levels of porphyrin precursor porphobilinogen (PBG) is normal in PCT.

Treatment

Four complementary therapeutic strategies are available:

• Reduction of body iron stores
• Increase in porphyrin excretion
• Treatment of chronic hepatitis C and HIV infection, when present
• Cessation of alcohol use, smoking, and estrogen use, when present

The mainstay therapies of PCT are phlebotomy and hydroxychloroquine. Depending on the specific comorbidities and susceptibility factors, one may be chosen over the other.

Prognosis

The life expectancy of patients with PCT is expected to be normal unless there are comorbid conditions like HCV that could lead to liver disease or carcinoma. Full remission is achievable, but recurrence is possible.

Post-transplant erythrocytosis

PTE is thought to be caused by overly robust erythroid production from the allograft and/or native kidneys. Risk factors include male gender, normal haemoglobin/haematocrit pre-transplant, renal artery stenosis, and a well-functioning graft. Patients with PTE often experience mild symptoms like malaise, headache, fatigue, and dizziness.

The first-line treatment for PTE is the use of angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARBs), which have been shown to be effective in reducing haemoglobin and haematocrit levels. Phlebotomy is a second-line treatment option, but it can lead to severe iron deficiency if performed repeatedly.

Frequently asked questions