Ob-Gyn Coding Alert

"Most ob/gyns agree that administering a fecal-occult blood test, particularly to patients older than 50, is an important screening tactic for early detection of colorectal cancer. But because of Medicares sometimes-confusing rules about what is and isnt covered regarding preventative or screening care, ob/gyns who administer these tests arent always certain whether it is a covered benefit. Coding when the test is for screening purposes versus when it is not also presents challenges. Diagnostic tests require different ICD-9 codes than screening exams, and no two state Medicare policies seem to agree on a policy for the tests. The key to getting reimbursed for fecal-occult blood tests is to distinguish between screening and diagnostic and to link the correct diagnoses code to the correct procedure code.

Fecal-occult blood tests have two different procedural codes:

HCPCS code G0107 colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations.

CPT code 82270 blood, occult; feces, 1-3 simultaneous determinations.

In either case, the physician is administering the exact same test in the same manner. The two tests even reimburse at about the same rate, around $3.50. So what is the difference?

Code G0107 is for a screening test. It is administered to patients older than 50 who have no signs or symptoms of colorectal cancer. It is done as a precautionary measure when patients reach an age when they are at higher risk for developing colon cancer. Medicare will pay for one G0107 test every year for patients over 50 years of age, and there must be at least 11 months in between the annual tests. According to Melanie Witt, RN, CPC, MA, an independent coding educator, Medicare added some screening tests in 1998. Prior to 1998, they would pay only for a screening Pap smear. Medicare calls this screening rather than preventative care because of their policy against paying for preventive care, Witt says. But they recognize that there are patients who are in a high-risk group because of their age who have a greater likelihood of developing disease. This increased recognition of high-risk groups has been beneficial to women on Medicare, as the program now pays for periodic routine screening exams for breast cancer, cervical cancer and other diseases of the female reproductive system. Like these other screening services, G0107 is a preventive step to look for early signs of colorectal cancer. The Medicare standard is now to cover the test every year to patients older than 50, even if no symptoms are present.

Code 82270 is for a diagnostic test. It is administered when the patient shows signs or symptoms of colorectal cancer, like blood in the stool, for example. If the patient has symptoms that lead the physician to believe that they have to eliminate colon cancer as a possible diagnosis, 82270 is reported by the physician, Witt explains. Medicare will pay for a diagnostic test at any time, as long as the correct procedural code is used, and the appropriate diagnostic code accompanies it.

Finding the Right ICD-9 Code

Once youve determined whether the fecal-occult exam was screening or diagnostic, the correct ICD-9 code has to be paired with the procedural code. For G0107, the choices are fairly straightforward. Since there does not need to be any signs or symptoms in the patient in fact, none should be present for G0107 there are two primary choices.

V76.41 special screening for malignant neoplasms; rectum, or

V76.51 special screening for malignant neoplasms; colon.

Some Part B carriers will also accept a personal or family history of cancer as justification for G0107, using codes V10.05 (personal history of malignant neoplasm; large intestine) or V16.0 (family history of malignant neoplasm, gastrointestinal tract). But again, because G0107 is a screening test, no additional signs or symptoms are required.

With 82270, signs or symptoms of disease have to be present in the patient. The diagnostic codes to indicate signs and symptoms vary widely between Part B carriers. For example, Blue Cross/Blue Shield (BC/BS) of Alabama, the Part B carrier for that state, lists 32 different ICD-9 codes or groups of codes as reimbursable with the 82270 test. These include (but are not limited to) some obvious choices, including family history of cancer and the presence or suspicion of malignant neoplasms elsewhere in the digestive system:

V10.00-V10.09 personal history of malignant neoplasm (specify site)
V12.71 peptic ulcer disease
V12.72 colonic polyps
V12.79 diseases of digestive system, other
150.0-150.9 malignant neoplasm of esophagus (specify site)
151.0-151.9 malignant neoplasm of stomach (specify site)
152.0-152.9 malignant neoplasm of small intestine (specify site)
153.0-153.9 malignant neoplasm of colon (specify site)
154.0-154.8 malignant neoplasm of rectum, rectosigmoid junction, and anus (specify site)

The list of approved codes for BC/BS of Alabama also includes about half of the ICD-9 codes for diseases of the esophagus, stomach and duodenum, as well as several other codes, including those for abdominal pain, swelling and tenderness.

Noridians list of approved codes for Part B providers in Colorado, North Dakota, South Dakota and Wyoming includes many of the same codes as BC/BS of Alabama, omits several from the BC/BS of Alabama list, and includes others not on BC/BS of Alabamas list, such as:

003.0 salmonella gastroenteritis

003.8-009.3 This section of codes covers salmonella infection, specified, unspecified and virtually every other bacterial infection of the intestine, such as botulism (005.1), giardiasis (007.1), E. coli (008.00-008.04) and infectious diarrhea (009.2).

The examples of Noridian and BC/BS of Alabama are indicative of the variety of ICD-9 coding options available to ob/gyns (and other practitioners) who administer 82270, depending on the state where they practice. The Web site www.lmrp.net is an extremely useful tool for finding each Part B carriers policy and approved ICD-9 codes for both the G0107 and 82270 tests.

Finding the Right Way to Administer the Tests

Even more confusing to ob/gyns and other practitioners is the method by which the fecal-occult blood test is supposed to be given. And because Medicare does not specify on the national level how the test is to be administered, it is back to local Part B policies, which, like the ICD-9 codes, vary widely from carrier to carrier.

There are essentially two different sets of rules about how the test is to be given. One states that the patient must be handed a test card on which to apply samples from three separate stools. The card is then returned to the office for testing. The other set of rules states that the test could take place either from a stool sample that is brought to the office by the patient, or during a digital rectal exam.

Noridian describes the test as follows:

Fecal-occult blood testing is a simple office or bedside diagnostic procedure in which a small amount of feces obtained either during rectal exam or from a stool sample is transferred to chemically impregnated paper on a card (Hemoccult and HemoQuant are two types). Developer is then added, and a color change indicates the presence or absence of hemoglobin in the feces.

But the policy goes on to state, Testing is usually performed on three separate specimens collected over a period of days, which would presumably make it difficult for this to be a simple office or bedside diagnostic procedure.

Nationwide Mutual Insurance Company, the Part B carrier for Ohio, is more specific and restrictive in its language:

Testing for occult blood in fecal samples is done by means of a guaiac-based test for peroxidase activity. Samples from two different sites of three consecutive stools are tested, implying that the test almost certainly involves the patient taking home the test card for sample collection.

In addition to more documentation requirements for claims, the guidelines for Trans America Occidental Life Insurance Company, the Part B carrier for Alaska, Arizona, Colorado, Hawaii, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming clearly indicate that the beneficiary (patient) must take the test card with her, collect stools samples and return it to the office for testing.

The fecal-occult blood test requires a written order from the beneficiarys attending physician. The term attending physician is defined as a doctor of medicine or osteopathy (as defined in Section 1861 [r] [1] of the Act) who is fully knowledgeable about the beneficiarys medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiarys specific medical problem.

The screening fecal-occult blood test means a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools, according to Trans America.

Reality is Less Complex

If you were to go by what some carriers say in their policies, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., you would send the patient home and tell them to extract a stool sample from two different locations in three separate stools six samples altogether. The likelihood of patients following through with this cumbersome not to mention unpleasant assignment would appear to be pretty slim.

Callaway feels, as does Witt, that despite the mixed messages being sent by Part B carriers, a fecal-occult blood test done in the office, with one stool sample collected from a digital rectal exam, will be reimbursed by Medicare if the appropriate diagnostic code(s) is used. There are plenty of doctors being paid for G0107 or 82270 when they conduct the test in the office, Callaway says. While a literal reading of the rules may indicate otherwise, reality is that the standard now is to conduct the test in-office.

Witt again emphasizes that the key piece in the reimbursement puzzle for these tests is not how they are given, but the diagnostic code applied. Coders must check either their carriers manual or the LMRP (local medical review policies) site to make sure they link the right ICD-9 code to the right test code. Fortunately, Witt says, Medicare realized a few years ago that these tests were worthwhile to both patient health and the programs expenditures, with the concept being that preventive or screening care is often less costly than treating an advanced-stage disease that could have been caught early. Now, she says, its just a question of getting everyone on the same page with regard to the rules of the tests."