Pathology/Lab Coding Alert

Don’t overlook newer procedures and codes.

If you’re stuck in the days of the tried-and-true guaiac test, you could be missing out on other lab procedures that clinicians might order for colorectal cancer (CRC) screening.

Check out our inventory of current test methods, then read “Follow Coverage Rules to Secure CRC Screening Pay” on page 35 to learn the rules that guide whether payers will reimburse for the services.

Choose Between 2 Codes For Guaiac Tests

The first line of defense for CRC screening is still often the basic fecal occult blood test (FOBT), also called a guaiac or peroxidase activity test. The assay involves applying a fecal smear on a card containing a substance originally extracted from a guaiacum tree, which will turn blue in the presence of a test reagent containing hydrogen peroxide only if blood is present in the stool.

Although CPT^® provides the following two codes to describe the procedure, you can see that only the first code describes a screening test:

• 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 3 cards or single triple card for consecutive collection)
• 82272, Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening

The lab test itself is identical for these two codes, but the test’s purpose is different, and the specimen collection might vary. Use 82270 only for a screening test using feces from three consecutive collections.

On the other hand, you should use 82272 only for a diagnostic test, says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M.

Get ‘FIT’ With Immunoassay Test

Some studies have indicated improved accuracy over guaiac tests using a newer test method called the Fecal Immunoassay Test, or FIT. This procedure involves mixing a reagent containing antihuman hemoglobin antibody with a fecal specimen. The antibody joins with any hemoglobin in the fecal specimen, if present, creating a clumping, or agglutination reaction, which the lab analyst measures as an optical change in the test mixture.

Clinicians may prefer this test over FOBT, both for accuracy and to avoid possible complicating factors, such as meat consumption or rectal bleeding, that can interfere with guaiac test results.

As with the FOBT tests, clinicians may order FIT for screening or diagnostic purposes. The lab may receive a fecal specimen for this test that the clinician obtained through a single encounter such as a digital rectal exam (DRE), or via home collection of three separate fecal specimens.

CPT^® provides just one code to describe the FIT test: 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations). But if you’re billing a screening FIT assay for Medicare beneficiary, you’ll need to report G0328 (Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous) instead.

Focus on Specificity With Molecular Test + FIT

An even newer test for fecal specimens involves using an algorithm to predict possible CRC based on the results of both the FIT test and a molecular diagnostics test to interrogate 10 DNA markers. The commercial test is called Cologuard.

The code for this test is 81528 (Oncology [colorectal] screening, quantitative real-time target and signal amplification of 10 DNA markers [KRAS mutations, promoter methylation of NDRG4 and BMP3] and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result).

The 81528 test is more sensitive than the FIT alone, which is why some clinicians order the test. However, the increased expense of the combination algorithm test, and the fact that it has a lower specificity than the FIT alone (meaning potentially more false positives leading to more colonoscopies) may mitigate its use.

Check Out Blood Test Option

CPT^® 2017 adds a new code for the only blood test currently available to screen for CRC — 81327 (SEPT9 [Septin9] [e.g., colorectal cancer] methylation analysis).

Good news: Many clinicians are anxious to use this test for their patients who currently won’t comply with fecal sampling or colonoscopy protocols to screen for CRC.

Usage of this test is expected to grow from about 20,000 to more than 100,000 tests annually, according to Mark S. Synovec, MD, vice chair of the CPT^® Editorial Panel, in his presentation at the CPT^® and RBRVS 2017 Annual Symposium. “This is based on reaching a fraction of the approximately 30 million people who are not currently adherent to colorectal cancer screening guidelines,” stated Synovec.

Know code change: Prior to January 2017, labs that performed this test reported Tier 2 molecular pathology code 81401 (Molecular pathology procedure, Level 2 [e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant (typically using nonsequencing target variant analysis), or detection of a dynamic mutation disorder/triplet repeat]…). CPT^® 2017 removes the SEPT9 mutation from the 81401 analyte list and directs coders to the new code 81327 instead.

Report Pathology Specimen Exam

Clinicians may order procedures such as sigmoidoscopy or colonoscopy to screen for CRC, or to diagnose cancer in patients with a positive screening lab test such as FOBT. In any case, labs may process a specimen removed during a scope procedure, which the pathologist will diagnose and report with an appropriate code. “For instance the pathologist might examine a colon biopsy or a polyp,” says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark. In either case, you should code 88305 (Level IV - Surgical pathology, gross and microscopic examination … biopsy colon OR … colorectal polyp …).

Bottom line: Whether coding a simple colorimetric lab test or a complex molecular test or pathology exam, you need to be familiar with a host of codes to capture your lab’s work for CRC screening.