I’m having some fun this week teaching a unit in the online graduate hemostasis course at the University of Medicine and Dentistry of New Jersey at the invitation of Drs Elaine Keohane and Nadine Fydryszewski. This also gives me the opportunity to work with colleagues Donna Castellone and Dr. Larry Smith. Many of our twelve students are seasoned veterans in hematology and coagulation laboratories. Here is a comment about PT/PTT screens from graduate student and lab manager Steve Marionneaux:
Just a comment about the prothrombin time (PT) and partial thromboplastin time (PTT) being used for pre-operative testing. While this practice has been around for years and remains in many pre-surgical protocols, Medicare no longer regards these tests as medically necessary for patients with no history of coagulopathy. According to an extensive search of the literature, no compelling evidence was found which showed that PT/PTT screening prior to surgery predicted the potential for bleeding in a patient with no history of a bleeding/clotting problem. Of course, surgeons continue to insist that we draw the tests. However, in these cases the patient is required to sign an advanced beneficiary notice (ABN) which is an agreement that the patient would pay for the tests. When asked why, it was a little uncomfortable, but we told the patient that they should discuss with their doctor.
This note was added by another grad student: Coding has been an increased issue, one I deal with on a daily basis. Not only does Medicare no longer pay for these tests for “pre-operative” purposes, same for several of the major private payers including BCBS and United Healthcare. We still are able to get the tests covered using v58.61 (long-term anticoagulant use) for those patients who have been on aspirin, Plavix, coumadin, etc. and 782.7 (spontaneous ecchymoses) for those with a history of easy bruising. These two typically cover about 40% of our patients who have PT/PTT pre-surgical orders. All others we have sign the ABN. At least these two tests are relatively inexpensive. We never tell the patient that the test itself is medically unnecessary, just that their insurance company dictates that they are. Yes, it is the laboratory’s place to review a doctor’s order, especially when there is no evidence to support the ordering of the test for the patient’s condition, however, to tell the patient that the test their physician ordered is medically unnecessary is potentially telling the patient their physician is incompetent and can result in the physician no longer utilizing your particular laboratory’s services. Telling a patient that their insurance will not cover the test is much different that telling them that their physician ordered a test that is not medically necessary (regardless if it is or not).