Part B Insider (Multispecialty) Coding Alert

Hint: Know the reason for the testing before you nail down a code.

If you want to keep the dollars flowing for in-office examination of fecal occult blood test (FOBT), you should focus on the difference between three hemoccult codes and their purpose.

Consider the following scenario:

A patient presented in the office complaining of diarrhea preceded by intestinal cramping, which lasted a couple of weeks. The patient is 60 years old and has no history of cancer in the family. She also didn’t feel nauseous at all. The physician took a stool sample to test for both parasites and blood. How should you tackle this?

Assign the Appropriate Code for Each Type of Collection

CPT^® has two codes that you can use for post digital rectal exam (DREs) and consecutive specimen collection:

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 (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening

Note: In the above scenario, it’s not clear whether the physician examined the samples herself or sent them to the lab. However, as a general practice, parasite exams almost always take place in the lab. In this case, the lab would be paid for the test directly. It is also not clear whether the sample for blood was collected as a screening or diagnostic test.

Ask Reason for the Test

"Why" is the keyword that can lead you to the correct CPT^® for FOBT, so don’t hesitate to find out the reason your ob-gyn has ordered it. If the test is for screening purposes, then you should report either 82270. The ICD-9 code for screening hemoccults should be V76.51 (Special screening for malignant neoplasms colon).

ICD-10: When your diagnosis system changes, you will report Z12.11 (Encounter for screening for malignant neoplasm of colon) instead.

Don’t forget: There are interval limitations for screening established by Medicare and most commercial carriers.

On the other hand, if a patient presents to the office with symptoms, the ob-gyn would perform a diagnostic FOBT, and you should bill it with 82272. "CPT^® 82272 can be billed if 1 to 3 specimens are obtained. The diagnosis code for the test would be related to the patient’s presenting symptoms," says Michael Weinstein, MD, a physician in Washington, D.C., and former member of the AMA’s CPT^® Advisory Panel.

Example: A 57-year-old patient presents with abdominal pain and dark stools. The physician collects a sample during a digital rectal exam. You should report the stool analysis with 82272. Because the physician orders the test for a symptom that the patient has (789.00, Abdominal pain, unspecified site), you can assume the service is diagnostic.

ICD-10: When your diagnosis system changes, you will either report R10.9 (Unspecified abdominal pain) or R10.0 (Acute abdomen).

Tread Carefully With the Number of Units

Although 82270 involves analysis of three specimens, you should always assign 82270 with a "1" in the units field. Some coders incorrectly interpret 82270’s descriptor of to mean they should bill each of the three determinations with one unit of CPT^® 82270 (82270 x 3). The description reminds providers that the code identifies three consecutive determinations.

Additionally, Code 82272 states "1-3 simultaneous determinations" but the quantity is still "1" whether 1 or 3 is performed.

Determine Who Obtains the Sample

Where the sample is collected and who performs it can also clue you in to the correct FOBT code. "CPT^® 82270 will always be billed as a separate service when the developer has been placed on the cards after the three completed cards (or one completed triple card) have been returned to the office," explains Weinstein. In short, the physician should not collect the specimen in the office.

You should instead assign 82272 when the physician performs a digital rectal exam in the office and obtains a sample at that time, but note that this is never considered a screening FOBT. CPT^® has made it very clear that physician collection can only be performed when the test is done for diagnosis of symptoms.

Example: An ob-gyn sees a 72-year-old patient for follow-up of gastroenteritis. During the visit, the physician discusses the importance of colorectal cancer screening with the patient. The ob-gyn sends the patient home with a screening kit that includes three FOBT cards and instructions for specimen collection and return. You should report the specimen analysis with 82270.

Extra: Sometimes, your choices don’t end with the two current hemoccult codes (82270, 82272). Make sure you know the specific type of stool test for blood because you might also use the CPT^® code for immuno fecal occult blood testing (iFOBT), warns Weinstein. In this case, you would report 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations) for the iFOBT test, and the appropriate ICD-9 for the patient’s symptoms. For routine colon cancer screening for Medicare patients, you would use G0328 (Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous) and V76.51. Caution: Medicare also requires that the patient collect the screening immunoassay sample so collection (and billing) by the provider at the time of the exam when the test is for screening is not permitted.