Gastroenterology Coding Alert

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 recently deleted one of its G codes for FOBTs.

Steer clear of FOBT coding follies with this expert advice.

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, confirms Melanie Witt, CPCOGS, MA, a coding expert based out of Guadalupita, N.M.

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," stresses Kent Moore, manager of health care financing and delivery systems for the AAFP in Leawood, Kan.

This FOBT takes a few days to complete, says Witt. "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," she says.

Example: A 66-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. 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.

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, says Moore, who directs coders to section 280.2.2 of Chapter 15 of the Medicare Benefit Policy Manual: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

In the chapter, the manual still refers to G0107, a nowdefunct screening code. Moore points out, however, that if you look in section 60.1(B) of Chapter 18 of the Medicare Claims Processing Manual (www.cms.hhs.gov/manuals/downloads/clm104c18.pdf ), it notes that 82270 replaced G0107 for dates of service January 1, 2007, and later.

Presenting Problem? Use Diagnostic Code Coding will change if the gastroenterologist has to perform the FOBT in-office because of a patient complaint, such as rectal pain or bleeding. Report 82272 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, 1-3 simultaneous determinations performed for other than colorectal neoplasm screening) when the physician performs an FOBT "for diagnostic purposes using peroxidase activity -- guaiac, for example -- and a fecal sample," relays Moore.

82272's aim: The gastroenterologist often has to perform this FOBT to "see if there is currently any [rectal] bleeding," Witt explains. 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," she says.

Example: A 68-year-old established patient reports to the gastroenterologist complaining of rectal bleeding and occasional dark stool. After a level-two E/M, the gastroenterologist performs the FOBT and notes some bleeding in the rectum. 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

• 569.3 (Other disorders of intestine; hemorrhage of rectum and anus) appended to 82272 to represent the patient's rectal bleeding

• 792.1 (Nonspecific findings in other body substances; stool contents) appended to 82272 to represent the patient's dark stool.

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 171 of this document: www.cms.hhs.gov/CoverageGenInfo/downloads/manual201001.pdf#23.

In 2009, Medicare deleted the endlessly confusing G0394 (Blood occult test [e.g., guaiac], feces, for single determination for colorectal neoplasm screening [e.g., patient was provided three cards  r single triple card for consecutive collection]), so coders are saved from having to decide when to use it. Even insurers could not decide on when G0394 was appropriate. For instance, some Aetna, Oxford, and Blue Cross/Blue Shield plans listed G0394 for colorectal cancer screening, while others such as Empire, Noridian, and TrailBlazer listed G0394 for diagnostic FOBT.