Internal Medicine Coding Alert

Code developers sort out 82270, 82272, G0107 misconceptions

When something's new, it always takes time to work out its kinks, and CPT's new DRE-related test code is no exception.

The creation of a separate CPT code for analysis of feces collected during a digital rectal exam (DRE) led many Internal Medicine Coding Alert readers to ask whether they could code a DRE for screening purposes and then send the patient home with the fecal occult blood test (FOBT) cards. At first, we said yes. But it turns out the answer is no.

Solution: We went to the code creators to bring you the inside scoop on coding:

• 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 three cards or single triple card for consecutive collection)

• 82272--Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, single specimen (e.g., from digital rectal exam)

• G0107--Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations.

Reserve 82270, G0107 for Screenings

First, you should use 82270 or G0107 to describe screenings only, says Glenn Littenberg, MD, a member of the American College of Physicians subcommittee on coding and reimbursement, which developed the code change language. That means that 82270 and G0107 should always be linked to a screening V code, such as V76.41 (Special screening for malignant neoplasms; other sites; rectum) or V76.51 (Special screening for malignant neoplasms; intestine; colon).

Revised code 82270 now echoes G0107 in its reference to a set of three cards that the patient takes home. You should bill either FOBT code "on the date the tests are run on the cards, not when they are given to the patient to take home," Littenberg says.

Important: Report 82270 or G0107 based on the insurer. You should report a colorectal cancer screening FOBT to a private payer with 82270. Use G0107 for Medicare. CMS will no longer accept 82270, effective April 1, 2006.

Describe Symptomatic Specimen Test With 82272

If a patient has a sign or symptom, stick with 82272. "We do not recommend DRE as part of colorectal cancer screening," says Lenonard Lichtenfeld, MD, FACP, deputy chief medical officer for the American Cancer Society. Possible indications for 82272 include:

• abdominal pain--789.00, Abdominal pain; unspecified site

• blood in stool--578.1

• dark stools--792.1, Nonspecific abnormal findings in other body substances; stool contents, such as "abnormal stool color."

Coverage update: Medicare did add 82272 to its list of accepted CPT codes, effective April 1, 2006, according to MLN Matters Number MM4328. CMS has not published a list of ICD-9 codes that will indicate medical necessity for 82272.

Forfeit FOBT DRE Payment

When you apply the above guidelines to daily life, a problem emerges. Internists may include a DRE as part of a routine physical exam, according to the American Cancer Society's colorectal cancer screening guidelines. "Doctors often find a small amount of stool during the performance of a DRE," the society says. "However, simply checking stool obtained in this fashion for evidence of bleeding is not an acceptable method of screening for colorectal cancer."

So what happens if your internist performs an FOBT DRE on an asymptomatic patient during a preventive medicine exam? "There is no payment for a test performed in the doctor's office in conjunction with a DRE," says Lichtenfeld, who is also the former CPT ACP representative.

Why: The internist is doing an in-office screening, which doesn't qualify for 82272 (diagnostic only) or 82270 (take-home screening only). So no method exists to correctly code the test.

However, treating this test as a noncodeable service is a good thing. "If one could use a V code for both 82272 and 82270 or G0107 for Medicare (even on different days), this may exceed a payer's allowed annual limits," says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.

Stick With 82272 for Take-Home Diagnostic Test

Since 82270 is for take-home tests only, it's easy to see how coders could assume 82272 is an in-office test. But if a patient is given a set of cards to take home for diagnostic purposes, you could bill 82272 with three units, Littenberg says.

In fact, you can report 82272 twice stemming from the same patient encounter. Here's how:

Suppose an internist tests a symptomatic patient's stool. Because the test is inconclusive, the physician sends the patient home with a set of cards for further testing. In this case, you could:

• report 82272 once for the in-office test from DRE, Littenberg says.

• also, report 82272 on the day that the patient returns the set of cards from the home test. "Report three units if all three cards are done, with whatever diagnosis applies," he says.

Problem: Insurers may not pay you for the three units, Littenberg says. "We understand that some payers' policy would be to pay only one unit of 82272."

For the above example, payers may also deny the second 82272. If the diagnoses support medical necessity for an in-office and take-home 82272, the insurer should pay for both tests, Littenberg says. But some payers may "put frequency limits on the test code so that the scenario would not be paid for," he says.

Challenge DRE-With-Office-Visit Bundle

Another potential payment problem involves the inappropriate but familiar all-inclusive office visit package. "We would like to be able to charge for the 82272 when our internists see a patient" on the same day as an E/M service, says Linda Thomas, billing specialist at The Keokuk Clinic in Iowa.

Good news: And indeed you can. Remember that 82272 is a diagnostic code, meaning the patient has a sign or symptom. So, you're going to use a problem visit code (99201-99205, Office or other outpatient visit ...), not a preventive medicine service code (99381-99397), in conjunction with 82272. Payers should not bundle a lab test into an E/M service, Littenberg says. "CPT language makes clear these are separate and distinct services."