Gastroenterology Coding Alert

If youre not billing payers for fecal occult blood tests (FOBTs) performed during an office visit, you could be throwing reimbursement dollars away. Practicing gastroenterologists and their coders can bill code 82270 (blood, occult; feces, 1-3 simultaneous determinations) for FOBT, also known as guaiac tests, separately from an evaluation and management (E/M) charge, and should be doing so, according to coding experts.

Although payers rules on FOBTs can differ, Glenn D. Littenberg, MD, a gastroenterologist in Pasadena, CA, and member of the American College of Physicians-American Society of Internal Medicines Committee on Payment and Coding, urges physicians to abandon traditions of bundling this test with E/M services because it is a lab test that has a designated code. And, he says, if a payer maintains that it is bundled, thats a decision that should be challenged. We have heard of GI practices that just dont bother to charge for FOBTs when they perform an E/M service (i.e., 99201-99205 or 99211-99215). So, does that mean you should never charge for other tests, such as a urinalysis or blood sugar? Where do you draw the line? he asks.

Littenberg says FOBTs are no different than any other tests performed by the physician during an office visit, and should be billed accordingly. It may be some coders habit to bundle the test, but since it has a code assigned to it, that certainly isnt the meaning of CPT, he insists.

Lost Revenue Adds Up

Although the reimbursement per test is low, typically $3 to $7 depending on the payer, Littenberg observes that those payments can add up, especially if your practice performs a lot of screening and diagnostic FOBTs. In his five-physician gastroenterologist practice, for example, Littenberg estimates that billing for FOBTs generates about $2,000 a year, assuming Medicare-equivalent reimbursement. We do a high volume of these tests, so small amounts turn into real dollars after a while. It can be a significant amount of money, depending on what your payer mix is, as there are some carriers who pay more than Medicare rates, he adds.

But Garnet Dunston, CPC, MPC, president of Dunston Enterprises Inc., a healthcare consulting company in Phoenix, AZ, says she has never seen an FOBT coded separately from an E/M service when the test is performed as part of an office visit. The former national secretary of the American Academy of Professional Coders says the only time she recommends the use of code 82270 is when the patient is given the set of three stool sample cards to take home. The CPT language stating one to three simultaneous determinations indicates the code should be used with the take-home sampling method, not the in-office test performed by the doctor during a digital rectal exam, because of the increased work involved, Dunston opines.

Littenberg acknowledges the take-home testing does involve more work and resource costs for the gastroenterologists office, including maintaining the cards, instructing patients in their use, and tracking when they are distributed to and returned by patients. In fact, he points out, the CPT panel did discuss creating a new code for the take-home test that would take into account the increased resource costs, leaving 82270 for the in-office test only. But the panel ultimately decided to make no changes, which left both types of FOBTs covered by the existing 82270 code, he says.

Coding for Multiple Determinations

In addition to billing 82270 for FOBTs done during a rectal exam, Littenberg says practices can bill an in-office test separately from the E/M code, plus bill the take-home sample cards separately for the same patient. So, if a patient has an FOBT done as part of a digital rectal exam, and also is given sample cards to take home, the doctor should bill 82270 for the test done during the office visit, and again when the patient returns the cards, using the date the results are determined (i.e., the dates the cards are processed). The key to billing the sample cards is the act of determining the result, he notes. In most cases, patients return the cards together, and the determinations are made at the same time. But if the patient returns each of the three cards at different times, he continues, each card theoretically could be coded separately, since 82270 indicates one to three simultaneous determinations. Under such circumstances, each result would be considered one determination, and if read on a separate date from the other cards, each would be billed individually.

A person may happen to return the cards at different times. Thats not the routine way of doing it for screening, but it may be done diagnostically. Patients may be thinking theyre passing very dark stools, and wondering if theyre bleeding. The best way to figure that out is to try to catch a stool test right at the time they see an abnormal-looking stool. So, they may do different cards at different times, and return them on different dates. Youre not running the determinations at the same time, and by strict interpretation of the code, it is legitimate to charge those out separately, says Littenberg.

He cautions, however, that payers rules on FOBTs and multiple determinations do vary. For example, Medicare bundles multiple determinations made within two weeks. So, even if you did one test in the office, and you sent home a set of cards later, and those cards were returned on three different days, if it all was within two weeks, Medicare would allow one determination. They would reimburse for one, and consider all the others part of the initial claim submitted, he explains.

Some commercial payers, meanwhile, will pay for each card separately if they are determined on different dates of service, plus pay for the FOBT done during the office exam separately. Other payers may have their own limits on what they will reimburse, or may follow Medicare policies. But, Littenberg stresses, such limits should not extend to bundling an in-office FOBT with the E/M service. The rare payer who tries to claim the test should be bundled as part of the E/M service ought to be told they dont understand, and should be sent a copy of the CPT definition, he declares.

Medicares FOBT Coding Rules

Another quirk in Medicare coding for FOBTs involves whether the test was done to screen for colorectal cancer. If so, it should be reported with HCPCS code G0107 (colorectal cancer screening; fecal occult blood test, 1-3 simultaneous determinations). However, this code is payable by Medicare only once per year for patients over age 50 who are entitled to Medicare Part B benefits, and who have no signs and symptoms of illness. According to coding advisers at the Bethesda, MD-based American Gastroenterological Association (AGA), the diagnosis code accompanying G0107 that is accepted by most Medicare carriers is V76.49 (screening for other malignant neoplasm). If your carrier has published another diagnosis code, you should use it instead, they recommend. Additionally, AGA coding advisers note that G0107 cannot be billed in addition to 82270.

If youre using FOBT diagnostically with a Medicare patient, then billing 82270 would be appropriate, explains Littenberg. But Medicare carriers will only pay for FOBTs billed with 82270 if the code is linked with an ICD-9 code that the carrier considers justification for ordering the test. To properly bill 82270 to Medicare, GI practices should check their Medicare carriers lists for occult blood, feces to determine whether a particular ICD-9 code is covered.

Tip: Because of the Medicare limitations on reimbursement for FOBTs, Littenberg suggests gastroenterologists pay attention to why they want the test and how they plan to use it, and use the G0107 code carefully. If youre seeing a patient in the office, and the only reason for the fecal occult blood test during your physical, as part of a rectal exam, is as a screening test, then you would use the G0107 code. But, if you then give the patient a set of cards separately, you wont be reimbursed, because that will fall under the one-year time frame set by Medicare for this test when performed as a preventive measure. So, if you really want to do the screening test in a way thats most appropriate, you dont do the test in the office as part of the digital exam. The test is more accurate when done from the set of cards, so there would be no reason to do the in-office stool test, he says.

With most of her practices patients presenting with some kind of gastrointestinal symptoms, Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 19-physician practice that covers northern Georgia and extends into North Carolina, says she rarely uses code G0107. We use the G code occasionally, if the only reason the doctors are doing the test is because of a family history [of colorectal cancer]. But thats very rare. Most of our patients come in here with other symptoms, she says.

Parks says she bills 82270 with an E/M code for most patients, including those covered by Medicare. Even when physicians perform the FOBT as part of an office visit, and then give patients the cards to gather specimens at home, Parks says she bills each test separatelycoding 82270 each time they are returned. We can bill Medicare for all three tests, but they will only pay for one. The commercial insurance, though, will allow all three, she says. Her practice charges $15 each for 82270. This test is basically a lab test, and thats totally separate from an E/M service. Its an actual test that the doctor does to help determine the diagnosis, and weve had no problem with payers recognizing that, she says.

Watch Out for Double Billing
With Take-Home Tests

Most practices bill the take-home FOBTs on the date they are returned, but some use the date they are distributed to patients. Although billing on the date of distribution is technically incorrect, since the code is for the determination of the result of the test, Littenberg says it is perfectly reasonable for a practice to do so to better keep track of its charges. As long as youre not billing on different dates for the same thing, its legitimate to do it either way in my view, he says.

Meanwhile, Parks and Dunston advise against billing for the sample cards upon distribution, fearing the patient may not return the cards and the practice might falsely bill. Weve never billed them when they go out because if something happens, and the patient doesnt send them back, thats false billing. Its too dangerous, says Parks.

Dunston adds that in the case of Medicare patients, if a practice has billed Medicare in advance, and the cards are not returned, that could constitute fraud and abuse if they are audited.

I really dont think the government is going to make an issue out of this, Littenberg maintains. For the convenience of simply getting your charge ticket through and getting it into the computer, it makes a lot of sense to use the date you saw the patient and gave them the test, rather than the date the cards come back, he says. In his practice, for example, the date of billing the take-home FOBTs varies. Theres not one way we uniformly do it. A lot of times when the patients have been seen, but weve not given the digital rectal exam, we give them a set of cards, and we bill with that service date. If the patient is just coming in for their annual screening test and doesnt need a visit, then we typically bill the day the card is returned. It can be whatever works in your office, as long as youre not doing it twice for the same test and double billing.