Pathology/Lab Coding Alert

Remember, G0394 is not for screening

Here's a head-scratcher--Medicare cleaned up screening fecal-occult blood test (FOBT) coding for 2007 by eliminating the need for a HCPCS level II code--then added a different HCPCS level II FOBT code. So, what should you do? Here's the advice from the experts.

You haven't been using G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations) since Medicare deleted the code effective Jan. 1. But do you know how to use the code added at the same time--G0394, Blood occult test (e.g., guaiac), feces, for single determination for colorectal neoplasm (e.g., patient was provided three cards or single triple card for consecutive collection)?

Get the Nitty-Gritty on G0394

Although the deleted HCPCS code was for screening, new code G0394 doesn't appear to be.

Confusion: Nobody's quite sure what you-re supposed to use G0394 for. On the one hand, it's clearly not a screening code because it's not on the -screening list,- says Melanie Witt, RN, CPC-OGS, MA, a coding expert based out of Guadalupita, N.M. On the other hand, it contains the reference to a -single determination- as well as to providing the patient with cards to obtain two or more samples.

So far, one carrier, Highmark Blue Shield, has weighed in on G0394 and instructed providers to use it for diagnostic FOBTs. That still doesn't explain how you can have a -single determination- as well as three cards, coding experts say.

Tip: You should keep using diagnostic code 82272 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, single specimen [e.g., from digital rectal exam]) when your physician only collects one sample in the office and doesn't send the patient home with cards, says Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis.

Rasmussen says one CMS official told her you could use G0394 if the patient is on -high-risk meds that cause GI bleeding.- You would bill this code with a diagnosis of high-risk medication, she says.

Bottom line: There are two situations when you might be able to use G0394, Witt says:

1. The patient comes in with a complaint including rectal bleeding, the doctor takes a sample in the office to confirm the diagnosis, and then sends the patient home with cards to obtain more samples.

2. The patient took cards home to check for rectal bleeding, and as a result of that test, the doctor takes an additional sample in the office.
 
Important: -Medicare developed this code for Medicare, so I wouldn't use this with any other payers,- Witt says.

Watch for NCCI bundles: To ensure that you do not report G0394 with any other FOBT code, the National Correct Coding Initiative bundled this code with 82270, 82272 and 82274. The code pairs have a modifier indicator of -0,- meaning that you cannot override the bundle under any circumstances.

Lab Method Determines Diagnostic FOBT Code

In addition to the rare cases when you might use G0394, you have two other FOBT codes to choose from when the physician orders a diagnostic test.

Remember: The physician orders a diagnostic test because of signs or symptoms of disease. If you bill a diagnostic FOBT, you must document a reason for it. For instance, if the patient is taking medications such as aspirin (V58.66, Long-term [current] use of aspirin) that can cause abdominal bleeding, the physician may order a diagnostic FOBT.

Commonly, the physician will obtain a specimen from a digital rectal exam that the lab tests using a guaiac-based assay (82272).

Avoid 82270: You should no longer use 82270 for diagnostic tests, according to the laboratory National Coverage Determination (NCD) for FOBT. Why? A single sample collected by DRE isn't clinically useful for screening purposes. Chances are if a physician collects a single specimen, it's a diagnostic test. That's why if the patient has a particular symptom, such as rectal bleeding (569.3, Hemorrhage of rectum and anus), you should use 82272.

Do this: That logic aligns with Medicare's FOBT rules--use 82270 for screening guaiac FOBT and 82272 for diagnostic guaiac FOBT.

Immunoassay is different: Labs may also perform an immunoassay FOBT, and that means using a completely different code--82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations).

Note frequency: For a diagnostic FOBT, Medicare will cover the test once every three months instead of once every 12 months for a screening test.