Pathology/Lab Coding Alert

You could be forfeiting your lab's $18 Medicare payment You have to know why and how your lab carries out a fecal-occult blood test (FOBT) if you want to know how to code -- and get paid -- for the test. Let our experts lead you through each step to maneuver Medicare's FOBT coverage rules. 1. Decide Whether FOBT Is Screening or Diagnostic When you're reporting to Medicare, you should code an FOBT based on whether the physician ordered a screening or diagnostic test. Medicare requires a different code for each test.

Example: A physician may order an FOBT to screen for colorectal cancer in a patient with no symptoms. Or a physician may order an FOBT diagnostically, to help determine the cause of another condition such as anemia (for example, 280.0, Iron deficiency anemias; secondary to blood loss [chronic]), that may be linked to undiag-nosed intestinal bleeding.

"You should report a screening FOBT for a Medicare beneficiary using the appropriate HCPCS Level II code -- either G0107, G0328 or G0328-QW for a CLIA [Clinical Laboratory Improvement Amendments] waived lab," says Anne Pontius, MBA, CMPE, MT (ASCP), president of Laboratory Compliance Consultants Inc., in Raleigh, N.C.

Report a diagnostic FOBT using an appropriate CPT code such as CPT 82270 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, 1-3 simultaneous determinations). See "Compare Fecal Blood Test Methods and Codes" for a comparison of the diagnostic and screening FOBT procedure codes and definitions.

How will you know if the test is screening or diagnostic? "For a screening test, the ordering physician will state that the FOBT is for colorectal cancer screening, or request the test with a screening code such as V76.51 (Special screening for malignant neoplasms; colon)," Pontius says.

But if the test is diagnostic, you can expect the physician to order the test with signs or symptoms, such as diarrhea (787.91, Diarrhea NOS). Or the physician may order a diagnostic FOBT when a patient has a known condition that may entail occult blood in the stool, such as salmonellosis (003.0, Salmonella gastroenteritis). 2. Check the Coverage Rules To learn Medicare's payment and coding rules for diagnostic FOBT (82270), you should review the agency's fecal occult blood test National Coverage Determination (NCD). Here are some signs, symptoms and conditions that justify a physician ordering a diagnostic FOBT, according to the NCD:

1. Known or suspected digestive tract condition that might cause intestinal bleeding (such as 004.0-004.9, Shigellosis; 005.0-005.9, Other food poisoning [bacterial]; or 009.0-009.3, Ill-defined intestinal infections)
2. Unexpected anemia (such as 280.0-280.9, Iron deficiency anemias)
3. Conditions that might be associated with blood loss (such as 780.79, Other malaise and fatigue)
4. To evaluate patient complaint of black or red-tinged stools (such as 787.7, [...]