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, Abnormal feces).

The NCD includes a complete list of covered diagnoses. Medicare will not pay for an FOBT when the physician uses an ICD-9 code not on the "covered" list. Also, watch out for Medicare's frequency restrictions, such as allowing an FOBT no more than once every three months for asymptomatic patients with a history of gastrointestinal bleeding who are on nonsteroidal anti-inflammatory drugs.

"Remember that the FOBT NCD only refers to coverage for diagnostic tests, not screening tests," says Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, director of coding and analysis for National Health Systems Inc., a coding consultation company in Camp Hill, Pa.

Medicare has a separate NCD for colorectal cancer screening that defines coverage rules for screening FOBTs reported with codes G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations) and G0328 (Fecal blood screening immunoassay). Once per year, Medicare covers either one guaiac-based (gFOBT) or one immunoassay-based (iFOBT) fecal-occult blood test for beneficiaries age 50 years and older. Either test serves to screen for colorectal cancer. Medicare added coverage for iFOBT beginning Jan. 1, 2004, because the test may require fewer specimen collections and is not as sensitive to dietary interferences.

Protect yourself: Ensure that you have a signed advance beneficiary notice if your lab performs an FOBT without a payable diagnosis. Otherwise, the lab can't bill the patient and must assume the cost of the test.

3. Determine the FOBT Lab Method

Before you can accurately code an FOBT procedure, you have to know whether the lab used either an immunoassay or a guaiac-based hemoglobin test. The immunoassay test identifies the globulin portion of the molecule. The guaiac-based test shows peroxidase activity in the heme moiety.

How it works: For the guaiac-based test, report either 82270 or G0107. Both definitions include the language 1-3 simultaneous determinations. Each testing encounter includes analysis and interpretation of up to three specimens, according to Medicare's lab NCD for FOBT.

"In other words, don't report three units of 82270 or G0107 just because the lab examines three fecal specimens for peroxidase activity," Wolfgang says.

If the lab performs the immunoassay test, you should report the service as 82274 or G0328. As with the guaiac tests, report the appropriate immunoassay code once for one to three specimens.