Gastroenterology Coding Alert

Get your patient involved before billing 82270.

Coding for your gastroenterologist’s fecal occult blood tests (FOBTs) depends heavily on patient status at the time of the test. Further, you’ll have to remember that Medicare has deleted one of its G codes for FOBTs. Ensure full points for your FOBT coding efforts with this expert advice.

Tip 1: For Patients Without Symptoms, Choose 82270

Report 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 your gastroenterologist’s screening tests.

On 82270 claims, the patient must take the cards home, obtain the samples himself, and return them to the physician. It is a requirement for reporting this code.

This FOBT takes a few days to complete. In order to be a screening test using the guaiac method, the patient must follow dietary and medication restrictions for three days prior to collecting the samples; three consecutive [specimens] is considered the standard.

Example: A 68-year-old Medicare patient comes in on Monday to obtain his FOBT exam cards; he has never had an FOBT before. The nonphysician practitioner (NPP) instructs the patient on how to collect the specimens, and answers a few questions the patient asks about what he’s “allowed to eat and when.” Total encounter time is about five minutes. On Friday, the patient returns the FOBT cards; he has followed all of the instructions and obtained three proper specimens on separate cards.

On the claim, report the following:

• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified healthcare professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services. .) with a Monday service date for the office visit

• 82270 with a Friday service date for the FOBT.

Tip 2: 82272 Comes In for Symptomatic Patients

On the other hand, if a patient presents to the office with symptoms, the gastroenterologist would perform a diagnostic FOBT, and you should bill it with 82272 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces,1-3 simultaneous determinations, performed for other than colorectal neoplasm screening). You can bill CPT® code 82272 if one to three specimens are obtained. The diagnosis code for the test would be related to the patient’s presenting symptoms.

If you’re still not sure whether you’ve got the right code by differentiating screening from diagnostic, you can look further into the test’s details. Identify how many tests the gastroenterologist or lab performs. For a three-specimen collection, you would use 82270. Report a single-specimen collection with 82272.

82272’s aim: The gastroenterologist often has to perform this FOBT to see if there is currently any [rectal] bleeding. If the gastroenterologist cannot detect any bleeding, he’ll send the cards home with the patient for a screening test or send the patient for a diagnostic colonoscopy or sigmoidoscopy if blood is detected.

Example: A 55-year-old established patient reports to the gastroenterologist complaining of abdominal pain, rectal bleeding, and occasional dark stool. After a level-two E/M, the gastroenterologist performs the FOBT and notes some blood in the stool from the rectum but no obvious source. He schedules the patient for a diagnostic colonoscopy in three weeks and sends him home. On this claim, report the following:

• 82272 for the FOBT

• 792.1 (Nonspecific abnormal findings in stool contents) appended to 82272 to represent the patient’s positive occult blood from the stool. Under ICD-10, the code will crosswalk to R19.5 (Other fecal abnormalities).

• 789.00 (Abdominal pain unspecified site). After the ICD-10 implementation, you can replace 789.00 with either R10.9 (Unspecified abdominal pain) or R10.0 (Acute abdomen).

The diagnosis codes that prove medical necessity for 82272 might vary by payer, though the above presenting symptoms should suffice for any payer. If you’re unsure of a carrier’s 82272 limitations, check your contract or contact a rep. For Medicare payers, however, find a complete list of ICD-9 codes that prove 82272 necessity on page 146 of this document: 

http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201410.pdf

Tip 3: Keep Medicare in Mind for Annual FOBT 

Medicare allows beneficiaries who have reached age 50 to have a screening FOBT annually. As for other insurers, be sure to check what their policies are for screening FOBTs. Some may mimic Medicare, but it’s possible that the payer has its own FOBT frequency intricacies.

Caveat: Medicare coverage requirements related to 82270 may differ from those of private payers. For more info look at section 410.37 of Chapter 4 of the Medicare Benefit Policy Manual at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/downloads/410_37.pdf

Tip 4: Keep Track of Other Options for FOBT Reporting 

Sometimes, your choices don’t end with the two current hemoccult codes (82270, 82272). Make sure you know the specific type of stool test for blood because you might also use the CPT® code for immuno fecal occult blood testing (iFOBT). In this case, you would report 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations) for the iFOBT test, and the appropriate ICD-9/ICD-10 code for the patient’s symptoms. For routine colon cancer screening for Medicare patients, you would use G0328 (Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous) and ICD-9 code V76.51 (Special screening for malignant neoplasms colon). The same diagnostic code under ICD-10 will be Z12.11 (Encounter for screening for malignant neoplasm of colon).