Internal Medicine Coding Alert

Question: A new patient who says she has lost 15 pounds in two weeks and has severe, constant abdominal pain reports to the internist. After a level-three E/M on a Monday, the physician sends the patient home with a three-card packet for the patient to place stool samples on. The patient returns the cards to the office on Friday, and tests confirm that there is no blood present in the stool. We have a Clinical Laboratory Improvement Amendments (CLIA) waiver. How should I code for this encounter?

Missouri Subscriber

Answer: Provided you've got that waiver on file, the internist can code for the guaiac colorectal screening. Without the waiver, your internist won't be able to perform or bill for this test.

For this encounter, you would report the following:

• 82272 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening) for the FOBT with a date of service of Friday

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) for the E/M with a date of service of Monday.