Primary Care Coding Alert

Question: After performing a digital rectal exam (DRE), a family physician sent a package of three hemoccult cards home with a non-Medicare patient. The woman returned the cards later that week. Should I bill the exam and fecal-occult blood test (FOBT) on the DRE day or on the return date?

California Subscriber

Answer: You should bill each service on the performance date. For the DRE, you should report the appropriate-level E/M service (99201-99215, Office or other outpatient visit for the E/M of a new or established patient ...) to the private payer. When the patient returns the cards, bill 82270 for the FOBT.

You shouldn't report the test on the DRE day. The patient may not return the samples. In this case, you wouldn't bill for the test.