Pathology/Lab Coding Alert

Coding for fecal occult blood tests (FOBT) involves understanding the various tests and time frames described by the codes. Laboratories also need to be aware of the indications for FOBT for diagnostic and screening purposes. Without this knowledge, laboratories may not be reimbursed for these tests.

The purpose of an FOBT is to determine if the patient has blood in the stool, says Joy Richardson, MT (ASCP), medical technologist at Norton Healthcare in Louisville, Ky. The test is sometimes carried out in the physicians office when a fecal specimen is acquired during a digital rectal examination. Then the stool sample is treated with a reagent and examined for a color reaction that will indicate if blood is present, Richardson says.

More commonly, the patient collects the specimens at home. The physician sends the patient home with a test kit that includes three cards. The test instructions say to smear a small portion of stool on one card and repeat the procedure on separate days for the other two cards. When all the specimens are collected, the patient sends the cards to the laboratory for simultaneous occult blood determination using the same test method described above.

Despite the fact that the test in the office involves one specimen and the take-home test involves three, the same code (CPT 82270 , blood, occult; feces, 1-3 simultaneous determinations) describes both services. The CPT language clarifies this usage, says Collette Shrader, compliance and reimbursement educator at Wenatchee Valley Clinic, representing 160 providers and seven locations in central Washington.

Deciding Which Test to Use

There are various test kits and methods available to identify hidden blood in the stool, says Richardson. The type we use is a guaiac-based test, she continues. This test is the most sensitive for detecting lower-bowel bleeding and is the basis of most FOBT kits.

Many kits are approved for use in labs with waived status under the clinical laboratory improvements amendment (CLIA) certification. CLIA waived-status laboratories should report test code 82270 with the -QW (CLIA waived test) modifier for Medicare reimbursement.

Other methods include a hemoglobin immunoassay that is less affected by diet and a heme-porphyrin assay that is valuable for evaluating overall gastrointestinal bleeding. Although these tests are less common and involve different laboratory methods, also report them with 82270.

Diagnostic vs Screening Tests

Many medical conditions indicate reasons for conducting an FOBT. To code correctly, however, you must know whether the test is ordered for diagnostic or screening purposes, explains Shrader.

1. How do we code for screening tests? Medicare has approved the guaiac FOBT as a screening tool for colorectal cancer. According to the Health Care Financing Administration (HCFA) program memorandum AB-97-24, a screening FOBT is covered once every 12 months for beneficiaries 50 years of age and older. The screening is reimbursable in the absence of signs and symptoms of disease.

When used for colorectal cancer screening for Medicare patients, the [FOBT] should be reported using HCPCS code G0107 (colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations), states Shrader. Medicare will not reimburse the screening test if it is reported using code 82270, she continues. The diagnosis code indicating that the test is for screening purposes is V76.41 (special screening for malignant neoplasms, rectum).

2. What does the diagnostic test require? If an FOBT is ordered for diagnostic purposes, report it with code 82270. Medicare may also impose frequency limitations on diagnostic tests under certain circumstances. For example, some local carriers may restrict an FOBT to once every three months for patients taking non-steroidal anti-inflammatory drugs with a history or intestinal bleeding (absent any current signs and symptoms).

Conditions that indicate medical necessity for an FOBT include:

digestive tract conditions that might include intestinal bleeding,
unexpected anemia,
abnormal signs and symptoms associated with blood loss, and
patient complaint of black- or red-tinged stool.

Many local medical review policies (LMRPs) list covered ICD-9 diagnosis codes for these conditions, signs and symptoms. Coders need to know the local policies and check the medical record for an appropriate diagnosis code or comparable narrative. Without a payable diagnosis, 82270 will be denied by Medicare, advises Shrader.

If a physician orders a test without a payable diagnosis code indicating medical necessity, the patient should sign a waiver of liability called an advanced beneficiary notification (ABN) before the test is run. Without an ABN, the laboratory cannot bill the patient for the non-covered services.

Laboratories may need to educate physicians regarding the medical necessity requirements of FOTB and the appropriate use of waivers. The physician, not the lab, identifies the diagnosis or reason for the test. Similarly, the physician should require the ABN, because he or she sees the patient before the test is run.

Note: See the article on page 75 Capture Reimbursement With Medicare ABN for a sample ABN with in-depth information about how to use them.