Prothrombin Time (Addition of ICD-9-CM 289.81, Primary Hypercoagulable State as a Covered Indication)

Currently, almost all patients undergoing an invasive sugical or diagnostic procedure with a risk of significate bleeding at University Hospital are screened with a history, physical, platelet count, protime (PT) and activated partial thromboplastin time (PTT). This is done to predict and correct a propensity for bleeding or clotting secondary to the procedure. Obviously, everyone agrees that laboratory testing is prudent in patients with a personal or family history of bleeding or clotting. The debate centers on wether these blood tests should be performed routinely in patients without such a history. Many of these patients, while not having a history of bleeding, may have other acquired disorders that could make them at risk for thrombocytopenia or a caogulopathy (eg. mediations, cancer, ethanolism, ect.) while others do not. Confounding these considerations is the inaccuracy found in patient derived histories. Many might not know that they have received heparin prior to a procedure or they may not consider heavy menstrual bleeding or bleeding after dental extraction as significant. Also, many may not have had a past procedure that would definitely challenge the clotting system. A case has been made that performing platelet counts, PT and PTT tests prior to a procedure may not be necessary in asymptomatic patients without without a history of bleeding or clotting. The position is that the probability of finding a true positive situation that would lead to bleeding and clotting is low and that false positives would lead to further testing and delays in the procedures. And yet, our experiences as consulting hematologists are that hundreds of previously unrecognized persons at risk for significate bleeding are detected per year at our facility and, with intervention, can successfully undergo the procedure. In addition, we see at least one "clinical disaster" per month wherin a propensity to bleed or clot was not recognized antecedent to an invasive procedure or surgery resulting insevere and very expensive sequelae. In the actuarial discussions regarding the use of these screening tests, it is never clear how much wieght is afforded the costs of these averted or known disasters (not just patient medical bills, but also lost work for them and their loved ones)and subsequent events prevented by the knowledge gained by these screening assays. I personally would still recommend their use. In fact, I might suggest that a PFA-100 be added to the screening algorithim to access platelet function given the amount of platelet inhibitor use that exists in the community.

Respectfully submitted,

Bernard J. Poiesz, MD
Director of Medicine
Regional Oncology Center

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