CPT 4044F Perioperative VTE Reimbursement | OpenPayer

Summary & Overview

CPT 4044F: Perioperative VTE Prophylaxis Order

CPT code 4044F documents a provider order for venous thromboembolism (VTE) prophylactic therapy given within 24 hours before or after a surgical procedure. As a perioperative quality and safety measure, this code captures the clinical decision to initiate VTE prevention in the immediate operative period, which is central to reducing postoperative morbidity and mortality nationally. The code is relevant to hospitals and surgical centers, clinicians managing perioperative care, and payers monitoring adherence to VTE prevention best practices.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what the code represents, the clinical contexts in which it is used, and typical sites of service. The publication outlines common benchmarking topics and policy considerations tied to perioperative VTE prevention documentation and billing. It also summarizes where data is available or missing for payers and highlights implications for billing workflows, quality measurement, and perioperative clinical protocols. Data not available in the input is explicitly noted where relevant.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare4044FCPTvenous thromboembolismVTE prophylaxisperioperative caresurgical qualityhospital billingorder documentation

Billing Code Overview

CPT code 4044F is reported when a provider documents the order to administer prophylactic therapy for venous thromboembolism (VTE) to a patient within 24 hours before a surgical procedure or within 24 hours after a surgical procedure. This code indicates the provider has ordered VTE prevention measures tied to the perioperative period.

Service type: Perioperative prophylactic therapy order for venous thromboembolism
Typical site of service: Hospital inpatient or outpatient surgical settings, preoperative holding areas, post-anesthesia care units, or other perioperative care locations where surgical patients are assessed and orders are placed

Clinical & Coding Specifications

Clinical Context

A typical patient is a 62-year-old male scheduled for elective total hip arthroplasty. He presents to the preoperative clinic the day before surgery for a history and physical and medication reconciliation. The surgeon documents an order for pharmacologic prophylaxis against venous thromboembolism (VTE), specifying agent (e.g., low molecular weight heparin or a direct oral anticoagulant), dose, timing, and anticipated duration. The order is placed within 24 hours before the surgical procedure. Perioperative nursing and pharmacy confirm the order, and prophylaxis administration is recorded in the electronic medical record. Postoperatively, the provider again documents or adjusts the VTE prophylaxis plan within 24 hours after surgery based on bleeding risk, renal function, and mobility status. This service supports quality monitoring and measure reporting that captures timely ordering of VTE prophylaxis around a surgical episode.

Coding Specifications

Modifier	Description	When to Use
`24`	Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period	Use when an unrelated E/M is provided during the global period of the surgery and the VTE prophylaxis order is unrelated to the procedure.
`25`

CPT 4171F: Erythropoiesis-Stimulating Agent Therapy for CKD-Related Anemia

CPT-4551F-PERFORMANCE-STATUS-MEASURE

CPT 4551F: Performance/Status Measure Entry

CPT-4005F-UNKNOWN-SERVICE

CPT 4005F: Undefined CPT Service Code Summary

CPT-4016F-UNSPECIFIED-SERVICE

CPT 4016F: Unspecified Service Entry

CPT-4178F-UNSPECIFIED-SERVICE

CPT 4178F: Unspecified Procedure or Service

CPT-4193F-SPECIFIC-CPT-MEASURE

CPT 4193F: Specific CPT Measure

CPT-4130F-4130F-NOT-SPECIFIED

CPT 4130F: Description Not Available

CPT-4230F-UNCATEGORIZED-SERVICE

CPT 4230F: Unspecified Clinical Service

CPT-4265F-NO-SUMMARY-AVAILABLE

CPT 4265F: No Summary Available

CPT-4557F-NO-SUMMARY-AVAILABLE

CPT 4557F: No Summary Available

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Taxonomy Code	Specialty	Notes
`207P00000X`	Orthopedic Surgery	Orthopedic surgeons commonly order perioperative VTE prophylaxis for joint arthroplasty.
`207L00000X`	Anesthesiology	Anesthesiologists may order or confirm prophylaxis as part of perioperative management.
`207RA0000X`	General Surgery	General surgeons order prophylaxis for abdominal and other surgical procedures.
`363A00000X`	Hospitalist	Hospitalists frequently document postoperative medication orders including VTE prophylaxis.
`371K00000X`	Vascular Surgery	Vascular surgeons manage elevated VTE risk and prophylaxis planning.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z48.89`	Encounter for other specified postprocedural aftercare	Used when documenting post-op follow-up where prophylaxis is addressed within 24 hours after surgery.
`Z79.01`	Long term (current) use of anticoagulants	Relevant when the patient is already on chronic anticoagulation and perioperative prophylaxis planning is required.
`Z98.890`	Other specified postprocedural states	Captures altered postprocedural conditions influencing prophylaxis decisions.
`I82.90`	Embolism and thrombosis of unspecified vein, unspecified site	Prior or current VTE history that increases the need for timely prophylaxis ordering.
`M16.11`	Unilateral primary osteoarthritis of hip, right hip	Example preoperative diagnosis for total hip arthroplasty where VTE prophylaxis is indicated.
`M17.11`	Unilateral primary osteoarthritis of knee, right knee	Example diagnosis for total knee arthroplasty where perioperative prophylaxis is ordered.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99203`	Office or Other Outpatient Visit for the Evaluation and Management of a New Patient, moderate complexity	Preoperative clinic visit where the VTE prophylaxis order may be documented within 24 hours before surgery.
`99232`	Subsequent Hospital Care, typically 25 minutes per day	Postoperative inpatient visit during which the provider documents or modifies VTE prophylaxis within 24 hours after surgery.
`36591`	Collection of blood for home testing by venipuncture; adults	Preoperative labs for renal function or coagulation studies that inform prophylaxis agent selection.
`90471`	Immunization administration (single or first component)	Not directly related but example of a separately reportable medication administration service; prophylactic medication administrations are recorded in medication administration records rather than billed as immunizations.
`99195`	Moderate sedation services for procedures performed by the same physician or other qualified health care professional in facility (if applicable)	Sedation/anesthesia services during surgery in which perioperative orders including prophylaxis are managed.

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