Pathology/Lab Coding Alert

You have to distinguish between Medicare's different fecal occult blood test (FOBT) policies if you want to get paid for your tests.

One set of rules is for colorectal cancer screening and requires unique codes and frequency limitations.

On the other hand, the laboratory national coverage determination (NCD) for FOBT involves a different set of rules for diagnostic tests. "These are FOBTs that a physician might order when a patient has a condition or symptom that could involve intestinal-tract bleeding," says Melanie Witt, RN, CPC-OGS, MA, a coding expert based out of Guadalupita, N.M.

Your job is to know the difference, and we-re here to show you how.

Medicare's colorectal cancer screening policy involves many procedures that won't affect your lab coding, such as colonoscopy, but FOBT is one screening test you do need to know about.

Depending on whether the lab performs a guaiac or immunoassay test, report the screening FOBT with one of two codes:

- 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)

- G0328 -- Colorectal cancer screening; fecal-occult blood test, immunoassay, 1-3 simultaneous determinations.

Make sure it's take-home: According to the policy, Medicare will cover a screening FOBT if the patient takes home cards, obtains fecal samples and returns the cards to the physician or laboratory. Don't expect screening-test payment if the physician takes a single sample from a DRE.

Beware of frequency limits: For beneficiaries aged 50 or older, Medicare will pay for one covered screening FOBT per year -- either 82270 or G0328, but not both.

You can read more about Medicare's colorectal cancer screening coverage at http://www.cms.hhs.gov/ColorectalCancerScreening/.

"When a physician orders an FOBT for a Medicare patient based on signs or symptoms of disease, you should follow the rules set forth in the lab NCD for the tests," Witt says.

According to that rule, indications for a diagnostic FOBT include the following:

- to evaluate known or suspected alimentary tract conditions that might cause bleeding into the intestinal tract

- to evaluate unexpected anemia

- to evaluate abnormal signs, symptoms, or complaints that might be associated with loss of blood

- to evaluate patient complaints of black- or red-tinged stools.

The NCD goes on to provide a list of "covered diagnoses," which you can access at http://www.cms.hhs.gov/CoverageGenInfo/Downloads/manual200704.pdf.

According to the FOBT lab NCD, you should report the test with one of the following two codes:

- 82272 -- Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening

- 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).

"If your lab performs the immunoassay instead of the guaiac test, you should use 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations) even though it's not listed in the NCD," Witt says.

Watch for different frequency rules: Although the NCD doesn't stipulate frequency for FOBT for most conditions, it does limit testing for patients taking NSAIDs:

"In patients who are taking non-steroidal anti-inflammatory drugs and have a history of gastrointestinal bleeding but no other signs, symptoms, or complaints associated with gastrointestinal blood loss, testing for occult blood may generally be appropriate no more than once every three months," according to the NCD.