How To Use CPT Code 4044F

CPT 4044F describes the documentation of an order for venous thromboembolism (VTE) prophylaxis to be given within 24 hours before or after a surgical procedure. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 4044F?

CPT 4044F can be used to document the order for prophylactic therapy for venous thromboembolism (VTE) in a patient within 24 hours before or after a surgical procedure. This code is used when the healthcare provider orders the administration of prophylactic therapy to reduce the risk of complications related to blood clots.

2. Official Description

The official description of CPT code 4044F is: ‘Documentation that an order was given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time (PERI 2).’ This code is used to indicate that the healthcare provider has documented the order for prophylactic therapy to prevent VTE in a patient undergoing a surgical procedure.

3. Procedure

1. The healthcare provider assesses the patient’s risk for developing venous thromboembolism (VTE) based on factors such as age, medical history, and the type of surgical procedure.
2. If the patient is at high risk for VTE, the healthcare provider documents the order for prophylactic therapy within 24 hours before the surgical procedure or within 24 hours after the surgical procedure.
3. The order should include the specific type of prophylactic therapy to be administered and the timing of administration.
4. The healthcare provider documents the date and time of the order in the patient’s healthcare record.
5. The order should be communicated to the appropriate healthcare professionals involved in the patient’s care to ensure proper administration of the prophylactic therapy.

4. Qualifying circumstances

Patients who are undergoing a surgical procedure and are at high risk for developing venous thromboembolism (VTE) qualify for the use of CPT code 4044F. The healthcare provider must document the order for prophylactic therapy within 24 hours before the surgical procedure or within 24 hours after the surgical procedure. The order should specify the type of prophylactic therapy and the timing of administration.

5. When to use CPT code 4044F

CPT code 4044F should be used when the healthcare provider documents the order for prophylactic therapy for venous thromboembolism (VTE) in a patient within 24 hours before or after a surgical procedure. This code should be used to indicate that the order has been given and documented in the patient’s healthcare record.

6. Documentation requirements

To support a claim for CPT code 4044F, the healthcare provider must document the following information:

• The patient’s risk for developing venous thromboembolism (VTE)
• The order for prophylactic therapy within 24 hours before or after the surgical procedure
• The specific type of prophylactic therapy to be administered
• The date and time of the order
• Communication of the order to the appropriate healthcare professionals involved in the patient’s care

7. Billing guidelines

When billing for CPT code 4044F, ensure that the healthcare provider has documented the order for prophylactic therapy for venous thromboembolism (VTE) within 24 hours before or after the surgical procedure. This code should not be reported with other codes related to VTE prophylaxis. It is important to follow the specific guidelines provided by the payer when submitting claims for CPT code 4044F.

8. Historical information

CPT code 4044F was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates to the code since its addition. This code was introduced to ensure proper documentation of the order for prophylactic therapy for venous thromboembolism (VTE) in surgical patients.

9. Examples

1. A surgeon documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours before a surgical procedure.
2. An anesthesiologist documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours after a surgical procedure.
3. A nurse practitioner documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours before a surgical procedure.
4. A physician assistant documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours after a surgical procedure.
5. A cardiologist documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours before a surgical procedure.
6. A gastroenterologist documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours after a surgical procedure.
7. An orthopedic surgeon documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours before a surgical procedure.
8. A urologist documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours after a surgical procedure.
9. A gynecologist documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours before a surgical procedure.
10. A neurosurgeon documents the order for prophylactic therapy for venous thromboembolism (VTE) to be given within 24 hours after a surgical procedure.