Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-43
Topic: Phlebotomy
Effective Date: August 1, 2005
Issued Date: September 10, 2007
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

A diagnostic phlebotomy for the collection or withdrawal of blood is an eligible service and should be reported under procedure code 36415, or S9529.

A phlebotomy by incision for the removal of a thrombus is an eligible service and should be reported under procedure code 34401-34490.

A phlebotomy performed for therapeutic purposes is an eligible procedure and should be reported under code 99195 (phlebotomy, therapeutic). The conditions/diagnoses under which a therapeutic phlebotomy can be paid are as follows:

  1. Polycythemia vera (238.4)
  2. Polycythemia secondary (289.0) to:
    • Cyanotic congenital heart disease (746.9) or Cor pulmonale (415.0, 416.9)
    • A-V fistulae
  3. Hemochromatosis (275.0)
  4. Porphyria cutanea tarda (277.1)

If a therapeutic phlebotomy is reported for a condition/diagnosis other than those listed, it should be denied as not medically necessary and, therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied service.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

344013442134451344713449036415
99195S9529    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Payment may be made for collection and handling of blood (i.e., diagnostic phlebotomy, see Medical Policy Bulletin L-2).

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 001 of S-43]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.