Gastroenterology Coding Alert

Gastroenterologists use the fecal-occult blood test to detect trace amounts of blood in the stool. They also use this test to diagnose a range of problems, because there are many causes of blood loss. Some common problems include Crohn's disease, ulcerative colitis, gastroenteritis, tuberculosis and tumors. The most common test used is the guaiac-based test because it is the most sensitive for detecting lower-bowel bleeding. The appropriate CPT code for this test is 82270 (Blood, occult, by peroxidase activity [e.g., guaiac] qualitative; feces, 1-3 simultaneous determinations).

Medicare designates this test as appropriate to evaluate alimentary-tract conditions that could cause intestinal bleeding, unexpected anemia, abnormal signs or symptoms that might be associated with blood loss, and complaints of discolorations in the stool. Report 82270 only once for the testing of up to three specimens. Medicare allows this test no more than once every three months for patients taking nonsteroidal anti-inflammatory drugs.

When the physician orders this test to screen for colorectal cancer in the absence of other signs, you should use code G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations). Medicare covers screening fecal-occult blood tests only when given once every 12 months to patients over the age of 50. This test requires a written order from the patient's attending physician. Although three specimens are collected for this screening test, a single claim should be made for the test with a single date of service and a unit of 1. Even though the physician may collect and submit the specimens for testing on different days, Medicare considers them simultaneous because the physician requested them at the same time.

Medicare holds that any test performed on a patient without any symptoms must be reported with the appropriate screening diagnosis code. Any condition discovered should be reported as a secondary diagnosis code. An acceptable diagnosis code for this screening test is V76.51 (Special screening for malignant neoplasms; colon). Linda Parks, MA, CPC, CCP, lead coder at Atlanta Gastroenterology Associated, warns coders to be careful with this G code because it will most likely be used only in rare circumstances, such as when the patient has a family history of colon cancer. In most cases, the patient will have other symptoms that should be reported with 82270.

There is a long list of diagnosis codes in the Program Memorandum on the CMS Web site. These codes are designated as diagnoses that show medical necessity, thus qualifying the tests for reimbursement. A wide range of symptoms and diseases is covered that includes the following:

Insurance companies, including Medicare, will deny claims for laboratory tests when their strict guidelines are not followed. According to the NCD, however, there are five sure-fire ways to lessen your chances of being denied for coverage:

1. Meet medical necessity. Be sure that any tests performed are reasonable and necessary for the diagnosis or treatment of the disease in hand. This includes listing the appropriate, covered diagnosis code for the test. Also, documentation is required to establish the medical necessity of tests. Documentation should include signs, symptoms, or abnormal findings that prove the medical necessity for ordering the tests. Second, it must show that the treating physician or other qualified nonphysician practitioner ordered the test.

2. Be aware of compliance issues. You need to comply with Medicare determinations pertaining to tests for screening purposes in the absence of symptoms, complaints, or personal history that are not covered.

3. Watch out for frequency exceptions to these tests. For example, the fecal-occult blood test is limited to once every three months for certain patients.

4. Comply with CLIA regulations. Make sure that the lab performing the test complies with the guidelines of the Clinical Laboratory Improvement Amendments (CLIA) of 1988.

5. Use appropriate diagnosis codes. Review the ICD-9-CM codes that are denied by Medicare or other carriers. For example, Medicare lists several V codes that are not covered diagnosis codes for the hepatitis tests.