Pathology/Lab Coding Alert

Eliminate -orphan- code to clean up FOBT claims.

After three years of confusion about how to code screening vs. diagnostic fecal occult blood tests, CMS removes questions -- by removing a code.

The code in question is 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]), which was introduced in 2006.

In an emergency update to the 2009 Medicare Physician Fee Schedule (MPFS) dated Jan. 2, CMS directed contractors to "manually end-date code G0394 effective Dec. 31, 2008" and "manually remove code G0394 from the 2009 [MPFS] file."

The CMS notice aligns with the fact that HCPCS 2009 deletes G0394.

Regardless of how you-ve used this code in the past -- whether for screening or diagnostic FOBT, depending on your payer's direction -- you should no longer be reporting G0394 as of Jan. 1, says Melanie Witt, RN, CPC-OGS, MA, a coding expert based out of Guadalupita, N.M.

The AMA tried to clean up FOBT coding in 2006 by updating CPT codes to accommodate screening and diagnostic testing. CMS also eliminated a "G" code (G0107, Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations) that the agency had required for screening FOBT.

The CPT 2006 changes modified 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 three cards or single triple card for consecutive collection]) and added 82272 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, single specimen [e.g., from digital rectal exam]).

Enter the mystery code: But the same year, CMS added G0394 -- which left coders scratching their heads.

"Code G0394 was clearly not a screening code because it wasn't on Medicare's list for colorectal cancer screening," Witt says.

On the other hand, G0394 was on the laboratory National Coverage Determination (NCD) for diagnostic FOBT tests.

Carriers differed: Medicare payers showed no consistency regarding the code. For instance, some Aetna, Oxford, and Blue Cross/Blue Shield plans listed G0394 for colorectal cancer screening, while others such as Empire, Noridian, and TrailBlazer listed G0394 for diagnostic FOBT.

CPT 2008 weighs in: With an 82272 revision in 2008, CPT changed the specimen and the emphasis of the code.

The new 2008 definition for 82272 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening) emphasizes the purpose of the test (other than - screening), rather than the specimen type.

The 2008 82272 definition clarified that you should only use this code for diagnostic tests, says Jay Neal, a coding consultant in Atlanta

But the 2008 definition also allows you to report 82272 for either a DRE or a three-test card, rather than only for DRE as the old definition established.

Mystery deepens: In light of the 2008 changes that clearly defined FOBT codes for screening (82270) or diagnostic (82272) guaiac-based FOBT tests, G0394 seemed even more of an orphan code.

Mystery solved: By removing G0394 from the 2009 HCPCS and MPFS, coders are clear to follow the straightforward coding guidelines you-ll see in the following sections. Read on for more tips.

When the smoke clears from all the code changes and confusion, here's what you need to do if your lab performs a peroxidase-activity FOBT test (such as guaiac-based tests):

1. Determine if the test is diagnostic or screening: You-ll know by the ordering diagnosis.

If the physician reports V76.51 (Special screening for malignant neoplasms; colon) or V76.41 (Special screening for malignant neoplasms; rectum), you-ll know that the lab is performing a screening test.

On the other hand, if the physician orders the FOBT test based on a known condition or a disease sign or symptom, you-ll know that the lab is performing a diagnostic test. You might see the test ordered for conditions such as unexpected anemia (280.0-280.9, Iron deficiency anemias) or patient complaint of red-tinged stools (787.7, Abnormal feces), You can see a complete list of diagnostic FOBT "payable diagnosis" ICD-9 codes on the NCD Web site at www.cms.hhs.gov/CoverageGenInfo/downloads/manual200901.pdf#23

2. Do this for screening tests: Use 82270 for screening FOBT tests. As the code describes, make sure the test is for "consecutive collected specimens." According to screening 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.

3. Do this for diagnostic tests: Use 82272 for diagnostic peroxidase FOBT tests. You should use this code regardless of specimen collection method. The code allows "1-3 simultaneous determinations," so you may use the code for a DRE specimen or for a three-test card.

If your lab performs an FOBT by a method other than peroxidase activity, you can't use the codes for guaiac tests (82270 and 82272). Although the guaiac test is the most effective method to detect lower bowel bleeding, meat consumption or bleeding associated with a procedure can interfere with results.

That might be one reason a lab would perform an immunoassay FOBT, which is less affected by diet or proximal bleeding. The immunoassay method recognizes antigens on the globin portion of hemoglobin, as opposed to the guaiac test, which recognizes peroxidase activity of the heme moiety.

To report the immunoassay, list code 82274 (Blood, occult, by fecal hemoglobin determination by immuno-assay, qualitative, feces, 1-3 simultaneous determinations).

"For some payers, you can use 82274 for a screening or diagnostic FOBT immunoassay," Witt says.

Specimen collection doesn't matter: Like 82272, specimen collection doesn't matter for 82274. That means you can use the code for a single specimen collected from a DRE or from cards with up to three separate specimens.

Medicare screening is different: If you-re reporting a screening FOBT immunoassay to Medicare, you can't use 82274. Instead, you should report G0328 (Colorectal cancer screening; fecal-occult blood test, immunoassay, 1-3 simultaneous determinations).