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Official Description

Phlebotomy, therapeutic (separate procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Phlebotomy, therapeutic, is a medical procedure that involves the drawing of blood for therapeutic purposes. This procedure is specifically performed to address and correct dangerously imbalanced blood chemistry, which can occur in various medical conditions. The act of drawing blood in this context is not merely for diagnostic testing but is intended to alleviate specific health issues by removing excess blood components that may be contributing to the imbalance. Therapeutic phlebotomy is often utilized in conditions such as hemochromatosis, polycythemia vera, and other disorders where the reduction of blood volume or specific blood constituents is necessary for the patient's health. This procedure is classified as a separate procedure, indicating that it is distinct from other types of blood draws that may be performed for diagnostic purposes. Understanding the rationale behind therapeutic phlebotomy is crucial for medical coders and billers, as it ensures accurate coding and billing practices related to this specific intervention.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Therapeutic phlebotomy is indicated for several specific medical conditions where the removal of blood is necessary to correct imbalances in blood chemistry. The following are the primary indications for this procedure:

  • Hemochromatosis - A genetic disorder that causes excessive absorption of iron from the diet, leading to iron overload in the body, which can damage organs.
  • Polycythemia Vera - A blood disorder characterized by an increased number of red blood cells, which can lead to complications such as blood clots and increased blood viscosity.
  • Other Disorders - Conditions that may require therapeutic phlebotomy include certain types of blood disorders where the reduction of blood volume or specific blood components is necessary for patient health.

2. Procedure

The procedure for therapeutic phlebotomy involves several key steps that ensure the safe and effective removal of blood. Each step is critical to achieving the desired therapeutic outcome while minimizing risks to the patient.

  • Step 1: Patient Preparation - The patient is first prepared for the procedure, which includes obtaining informed consent and ensuring that the patient understands the purpose and potential risks associated with therapeutic phlebotomy. The healthcare provider may also review the patient's medical history and current medications to identify any contraindications.
  • Step 2: Site Selection and Sterilization - A suitable venipuncture site is selected, typically in the antecubital fossa (the bend of the elbow). The area is then cleaned and sterilized using an antiseptic solution to prevent infection.
  • Step 3: Blood Collection - A sterile needle is inserted into the selected vein, and blood is drawn into a collection bag or appropriate containers. The volume of blood removed is determined based on the patient's specific condition and treatment plan, often ranging from 450 to 500 mL.
  • Step 4: Post-Procedure Care - After the blood has been collected, the needle is removed, and pressure is applied to the venipuncture site to minimize bleeding. The site is then bandaged, and the patient is monitored for any immediate adverse reactions.

3. Post-Procedure

Post-procedure care for therapeutic phlebotomy includes monitoring the patient for any signs of complications, such as excessive bleeding, dizziness, or fainting. Patients are typically advised to rest for a short period after the procedure and to hydrate adequately. Follow-up appointments may be scheduled to assess the effectiveness of the treatment and to determine if additional phlebotomy sessions are necessary. It is also important for healthcare providers to educate patients on recognizing any potential side effects or complications that may arise following the procedure.

Short Descr PHLEBOTOMY
Medium Descr PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE
Long Descr Phlebotomy, therapeutic (separate procedure)
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 5 - Incident To Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator STV-Packaged Codes
Type of Service (TOS) 1 - Medical Care
Berenson-Eggers TOS (BETOS) P6C - Minor procedures - other (Medicare fee schedule)
MUE 2
CCS Clinical Classification 231 - Other therapeutic procedures
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service.
25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
CR Catastrophe/disaster related
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
JZ Zero drug amount discarded/not administered to any patient
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PN Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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