Gastroenterology Coding Alert

Without Clinical Laboratory Improvement Amendments (CLIA)-waived status, your practice is forbidden from performing lab tests that could net some more patients and reimbursement for the gastroenterologist.

CLIA-waived means that the gastroenterologist is certified to conduct simple lab services in-house, says Sean M. Weiss, CPC, CPC-P, CMPE, CCA-P, CCP-P, senior partner at The CMC Group LLC in Atlanta. "If a provider's office does not have a CLIA certification or other lab certification, they are not able to provide the [waived] service or bill for it," he says.

Fallout: If someone needs a CLIA-waived test, offices that don't have the waiver cannot provide the service.

The CLIA waiver can be a benefit to most gastroenterology offices -- but especially those that wish to perform H. pylori breath tests for their patients.

Example: The physician performs an upper gastrointestinal endoscopy and a rapid unease test to check for H. pylori on a 66-year-old established Medicare patient. On the claim, you would report the following:

• 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) for the EGD

• 87077 (Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate) for the biopsy examinations

• modifier QW (CLIA waived test) appended to 87077 to show that the practice has a waiver.

Payout: While the 87077 code has no relative value units (RVUs) attached to it, 43239 has 8.98 transitioned nonfacility RVUs, meaning a payout of about $320 per H. pylori screening via EGD (8.96 multiplied by the 2009 Medicare conversion rate of 36.0666).

Without a CLIA waiver, however, you cannot perform or code for this test.

Another CLIA-waived test a gastroenterologist can perform is the guaiac colorectal screening. Without the waiver, your gastroenterologist won't be able to perform this test.

Example: A new patient who says she has lost 15 pounds in two weeks and has severe, constant abdominal pain reports to the gastroenterologist. After a level-three E/M, the physician sends the patient home with a threecard packet for the patient to place stool samples on. The patient returns the cards to the office, and tests confirm that there is no blood present in the stool.

For this test, you would report the following:

• 82270 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening [i.e., patient was provided 3 cards or single triple card for consecutive collection]) for the FOBT

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99203 to show that the E/M and the fecal occult blood tests (FOBT) were separate services.

Payout: Code 82270 has no RVUs, but 99203 pays about $92 (2.55 RVUs times 36.0666).

Other tests your gastroenterologist might perform that require the waiver include:

• 81002 -- Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy

• 81025 -- Urine pregnancy test, by visual color comparison methods

• 82272 -- Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, 1-3 simultaneous determi nations, performed for other than colorectal neoplasm screening]

• 82274 -- Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations.

For more info: Check out the application for the CLIA waiver at www.cms.hhs.gov/cmsforms/downloads/cms116.pdf.