Medicare Compliance & Reimbursement

If your physician is one of the many who supports using screening DNA stool tests to detect the early signs of colorectal cancer, expect disappointment about a new CMS ruling.

On April 28, CMS issued a coverage decision memorandum outlining its stance on these new tests.

Although CMS acknowledged that selected physicians and associations had declared the DNA test a promising and cost-effective alternative to more invasive testing, the agency's decision came down to the fact that the only commercially available test currently on the market still requires premarket review, and therefore has not yet been cleared by the FDA, according to the decision memorandum issued by Steve E. Phurrough, MD, MPA, director of CMS' Coverage Analysis Group.

Stick with prior codes: The coverage decision reminds practices that fecal occult blood tests (FOBTs) are still payable for colon cancer screening, but many practices are still confused about how to report these services, considering that CPT has changed the codes several times from year to year.

As many practices noticed when they received their most recent copy of CPT, the 2008 descriptor for 82272 is "Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening."

Last year, the descriptor was "Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, single specimen (e.g., from digital rectal exam)."

The new definition replaced "single specimen" with "1-3 simultaneous determinations, performed for other than colorectal neoplasm screening."

Although the 82272 change aligns with Medicare rules and allows sampling-method flexibility for a diagnostic guaiac FOBT, it raises even more questions about when to use G0394 -- a code that Medicare added just last year.

The new 82272 definition clarifies that you should only use this code for diagnostic tests, says Jay Neal, a coding consultant in Atlanta.

Emphasis changed: The old 82272 definition emphasized the specimen-collection method -- digital rectal exam (DRE). But the new definition emphasizes the reason for the test, Neal says.

You can still use 82272 for DRE collections.

According to the AMA's CPT 2008 Changes: An Insider's View, "The inclusion of the phrasing '1-3' in the descriptor clarifies that 82272 is appropriately reported for assessment of either a single sample obtained from a digital rectal exam or for assessment of a three-test card prepared by the patient."

Screening code is different: If you perform a screening guaiac-based FOBT, you should continue to 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]).

Don't miss the screening specimen requirement: You should not use 82270 for a DRE specimen. The code definition makes this clear by specifying "consecutive collected specimens," and beginning the parenthetic phrase with "i.e.," which means "that is," -- not "e.g.," which means "for example."

Keep in mind: CMS granted "CLIA-waived" status to both tests described by codes 82270 and 82272, but according to CMS, you do not need to append modifier QW (CLIA-waived test) to either of these codes.

To read CMS' April 28 coverage decision regarding DNA stool tests, visit http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=212&.