Primary Care Coding Alert

Whether a practice can report diagnostic guaiac tests performed during a digital rectal exam (DRE) is a hotly contested issue in family practice coding. Some professional coders maintain that the code describing the service (82270, blood, occult, by peroxidase [e.g., guaiac]; feces, 1-3 simultaneous determinations) can only be reported when patients collect samples at home. Others contend that the test represents a discrete service during a DRE in the office and may appropriately be reported under those circumstances as well.

CPT and the majority of third-party payers support this latter position. Although a few insurers deny claims for 82270 when it is done in the office during an exam, most pay for the test as well as the E/M service.

Fecal occult blood tests (FOBTs) are used to determine if a patient has blood in the stool, explains Linda Parks, MA, CPC, coding supervisor for Atlanta Gastroenterology Associates in Atlanta, a 22-physician practice. One or more stool samples is obtained and treated with a developer. The samples are then examined under special lighting, and a change in color reveals whether blood is present.

In some cases, an FP will collect the sample during DRE. In other cases, a packet of three cards is sent home with the patient, who is asked to take stool samples at three different times. The cards are then returned to the office, where testing and determinations are made. It takes only one positive to identify blood in the stool, but three negative to determine a negative test.

How to Code FOBTs and Office Visits

An FP examines a patient and performs a DRE, which includes a stool sample that will be tested in the office. Coders should assign the appropriate E/M service (e.g., 99213, office or other outpatient visit, established patient) as well as 82270.

Coding experts cite two reasons that both may be billed. One strong argument can be found in the code description itself, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., which supports family practice physicians in Broomfield, Colo. It says the test includes one to three determinations. The physicians sample is one determination, which allows the service to be reported separately.

Parks says CPT has taken a clear stand on this issue, noting that the actual performance and/or interpretation of diagnostic tests or studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests or studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code.

Although both the E/M and FOBT code would be reported on the same date of service, no modifiers would need to be attached.

Any single-determination FOBT (i.e., during a DRE) needs to be documented and logged in the same manner as take-home cards. Usually, returned home tests are submitted to a laboratory, where the results are entered into the labs computer system and documented in the patients record. However, negative results during an office visit are frequently discarded because it takes three to be a true negative. This practice may result in nonpayment of the single-determination FOBT because the findings were not properly recorded. Instead, cards should also be submitted to the lab to be officially logged.

How to Code Take-home FOBTs

Coders would also report both an E/M to reflect the office visit and the FOBT when patients take the sampling cards home. However, the E/M code is reported for the date when the patient was seen, while 82270 is reported on the date when the cards are returned and read (i.e., the date the determination was made).

One error occurs in a majority of practices, says Parks. They bill the take-home tests on the day that they were sent with the patient. However, you have no way of knowing if the patient will actually return them. To code these correctly, you should wait until the cards have arrived back in your office and the determination is made.

In theory, because the determination reflects when the stool samples were analyzed and not when the patient took the sample, 82270 could be reported multiple times if the patient returns the cards separately. For example, a patient is seen in the office on a Monday and the physician sends a set of three FOBT cards home. The patient takes one sample and returns a card on Tuesday, and does the same on Wednesday and Thursday. In this case, the E/M service could be reported on Monday, and 82270 reported for the determinations made Tuesday, Wednesday and Thursday. This is rare, because most patients return the cards as a set. Also, many payers have set time limits, within which any determinations are considered part of one test. Some coders report that their carriers, for instance, require that two weeks lapse between guaiac tests.

Sometimes one stool sample is taken during a DRE and a set of cards is sent home with the patient. This may occur when the physician wants to confirm a negative result which, by definition, requires three samples. A physician who has suspicion about a patients symptoms may send home three cards to confirm the single negative done in the office.

In this case, an E/M and 82270 could be reported on the date of the office visit, and 82270 reported once again when the take-home cards are returned and analyzed. This scenario, too, may fall within any time limits payers have established. Coders should ask each insurer how to support the medical necessity of conducting the FOBT twice.

Take-home Tests Require More Work

Coders argue that FOBTs obtained during a DRE should be bundled into the E/M because this exam takes minimal work. The physician simply takes the sample during the course of the exam and reads it immediately. Take-home tests, on the other hand, require that office staff maintain the cards, instruct the patients in their use, and track when they are distributed and returned.

Because of these demands, Parks explains, some coders feel 82270 should be reserved to reflect the increased time and resources needed for take-home FOBTs. CPT once considered adding a new code for the take-home version, and leaving 82270 to describe in-office testing. That plan was abandoned, and CPT affirmed its intent that 82270 be used to report both types of testing.

Diagnosis Codes Must Support 82270

Most payers accept many diagnosis codes to support the medical necessity of a FOBT, says Page. These ICD-9 codes may include (but are not limited to):

005.0-005.9 bacterial food poisoning

151.0-151.9 malignant neoplasm of stomach

152.0-152.9 malignant neoplasm of small intestine, including duodenum

153.0-153.9 malignant neoplasm of colon

455.0-455.9 hemorrhoids

531.00-531.01 gastric ulcer, acute with hemorrhage

531.10-531.11 gastric ulcer, acute with perforation

535.00-535.01 acute gastritis

537.4 fistula of stomach or duodenum

555.0-555.9 regional enteritis (includes Crohns disease)

564.1 irritable bowel syndrome

783.0 anorexia

783.21 weight loss

787.99 change in bowel habits

789.00-789.09 abdominal pain

V12.79 personal history of diseases of digestive system, other

Guaiac tests are also conducted as a colon cancer-screening exam and under these circumstances reported with G0107 (colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations). Medicare allows colorectal cancer screening once every 12 months for beneficiaries age 50 and older. Diagnosis code V76.41 (special screening for malignant neoplasms, other sites, rectum) or V76.51 (special screening for malignant neoplasms, intestine, colon) should be reported with G0107.