How To Use CPT Code 85441

CPT 85441 describes the direct stain procedure performed by a lab analyst to evaluate a blood smear for the presence of Heinz bodies. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 85441?

CPT 85441 can be used to describe the direct stain procedure performed by a lab analyst on a blood smear to evaluate the specimen for Heinz bodies. This code is used when the analyst applies a specific stain, such as crystal violet, to the blood smear and examines it under a microscope to identify the presence of denatured hemoglobin inclusions known as Heinz bodies.

2. Official Description

The official description of CPT code 85441 is: ‘Heinz bodies; direct.’

3. Procedure

1. The lab analyst prepares a blood smear on a slide.
2. A specific stain, such as crystal violet, is applied to the blood smear.
3. The stained slide is examined under a microscope to identify the presence of Heinz bodies, which are denatured hemoglobin inclusions found in red blood cells.

4. Qualifying circumstances

CPT 85441 is performed when there is a need to evaluate a blood smear for the presence of Heinz bodies. This procedure may be ordered by clinicians to aid in the diagnosis of certain hemolytic anemias, G–6–PD deficiency, alpha thalassemia, or the presence of an unstable form of hemoglobin. It may also be used to evaluate possible ingestion of oxidizing chemicals or certain drugs.

5. When to use CPT code 85441

CPT code 85441 should be used when a lab analyst performs a direct stain on a blood smear to evaluate the specimen for Heinz bodies. It is important to distinguish this code from CPT code 85445, which is used for a test for induced Heinz bodies.

6. Documentation requirements

To support a claim for CPT 85441, the documentation should include:

• Reason for ordering the test
• Details of the staining procedure performed
• Microscopic examination findings

7. Billing guidelines

When billing for CPT 85441, ensure that the procedure is performed by a lab analyst. It is important to note that some payers may separately reimburse for the collection of the blood specimen using a code such as 36415 for venipuncture. It is also crucial to distinguish CPT 85441 from CPT 85445, which is used for a test for induced Heinz bodies.

8. Historical information

CPT 85441 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A lab analyst performing a direct stain on a blood smear to evaluate for Heinz bodies in a patient with suspected hemolytic anemia.
2. A clinician ordering a Heinz body stain to assess a patient with G–6–PD deficiency.
3. A lab analyst examining a blood smear for Heinz bodies in a patient who may have ingested an oxidizing chemical.
4. A clinician requesting a Heinz body stain to evaluate a patient with suspected alpha thalassemia.
5. A lab analyst performing a direct stain on a blood smear to assess a patient with a suspected unstable form of hemoglobin.