Pathology/Lab Coding Alert

Question: Our lab wants to start using PreGen-Plus, a commercially-available DNA stool test for colorectal cancer. Will payers cover this as a screening test, and how should we code it?

Texas Subscriber

Answer: CMS recently released a decision memo for a screening DNA stool test for colorectal cancer screening (CAG-00144N). According to this memo, Medicare will not cover PreGen-Plus for colorectal cancer screening until the Food and Drug Administration (FDA) approves a DNA stool test and CMS has the opportunity to reconsider coverage. You may contact your other payers to see if they cover the test.

Because several modifications of the test have been available, you need to know each of the molecular diagnostics steps involved in your particular test to select the correct CPT codes. For instance, the test might involve an extraction step such as 83891 (Molecular diagnostics; isolation or extraction of highly purified nucleic acid), amplification such as 83898 (- amplification, target, each nucleic acid sequence), identification such as 83896 (- nucleic acid probe, each) and 83904 (- mutation identification by sequencing, single segment, each segment), and interpretation (83912, - interpretation and report).

A HCPCS Level II code also describes colorectal cancer screening by DNA, but only use this code if instructed by a payer to do so: S3890 (DNA analysis, fecal, for colorectal cancer screening).

Know FOBT codes: At this time, fecal occult blood tests (FOBT) are the only lab tests covered for colorectal cancer screening by Medicare. 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.

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/.