Gastroenterology Coding Alert

Why, who, and where work hand-in-hand to point you to the right code.

If you want to keep the dollars flowing for in-office examination of fecal occult blood test (FOBT), you should focus on the difference between three hemoccult codes and their purpose.

Consider the following scenario:

A patient presented in the office complaining of diarrhea preceded by intestinal cramping, which lasted a couple of weeks. The patient is 60 years old and has no history of cancer in the family. He also didn't feel nauseous at all. The physician took a stool sample to test for both parasites and blood. How should you tackle this?

Assign the Appropriate Code for Each Type of Collection

Since 2007, CPT has assigned two codes that you can use for post digital rectal exam (DREs) and consecutive specimen collection:

• 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)
• 82272 -- Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, single specimen (e.g., from digital rectal exam)

Update: Effective January 1, 2007, CPT has terminated HCPCS code G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations), and replaced by 82270 even for routine Medicare screening FOBT, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

Note: In the above scenario, it's not clear whether the physician examined the samples herself or sent them to the lab. However, as a general practice, parasite exams almost always take place in the lab. In this case, the lab would be paid for the test directly.

Ask Reason for the Test

"Why" is the keyword that can lead you to the correct CPT for FOBT, so don't hesitate to find out the reason your gastroenterologist has ordered it. If the test is for screening purposes, then you should report either 82270. The ICD-9 code for screening hemoccults should be V76.51 (Special screening for malignant neoplasms colon).

Don't forget: There are interval limitations for screening established by Medicare and most commercial carriers.

On the other hand, if a patient presents to the office with symptoms, the gastroenterologist would perform a diagnostic FOBT, and you should bill it with 82272. "CPT 82272 can be billed if 1 to 3 specimens are obtained. The diagnosis code for the test would be related to the patient's presenting symptoms," notes Weinstein.

Example: A 57-year-old patient presents with abdominal pain and dark stools. The physician collects a sample during a digital rectal exam. You should report the stool analysis with 82272. Because the physician orders the test for a symptom that the patient has (789.00, Abdominal pain, unspecified site), you can assume the service is diagnostic.

Count Number of Tests

If you're still not sure whether you've got the right code by differentiating screening from diagnostic, you can look further into the test's details. Identify how many tests the gastroenterologist or lab performs. For a three-specimen collection, you would use 82270. Report a single-specimen collection with 82272.

Red flag: Although 82270 involves analysis of three specimens, you should always assign 82270 with a "1" in the units field. Some coders incorrectly interpret 82270's descriptor of "one to three simultaneous determinations" to mean they should bill "each of the three determinations with one unit of CPT 82270 (82270 x 3)," says Diana W. Voorhees, MA, CLS, MT(ASCP)SH, CLCP,  principal at DV & Associates Inc., in Salt Lake City. "The revised description more clearly reminds providers that the code identifies as many as three consecutive determinations," she writes in the article 2006 Laboratory Coding Changes.

What if: The patient fails to collect all three samples. You may still bill 82270. If this happens, the laboratory should perform analysis of the one or two collected specimen, report the results accordingly and record one unit of 82270.

Determine Who Obtains the Sample

Where the sample is collected and who performs it can also clue you in to the correct FOBT code. "CPT 82270 will always be billed as a separate service when the developer has been placed on the cards after the three completed cards (or one completed triple card) have been returned to the office," explains Weinstein. In short, the physician should not collect the specimen in the office.

You should instead assign 82272 when the physician performs a digital rectal exam in the office and obtains a sample at that time.

Example: A gastroenterologist sees a 72-year-old patient for follow-up of gastroenteritis. During the visit, the physician discusses the importance of colorectal cancer screening with the patient. The gastroenterologist sends the patient home with a screening kit that includes three FOBT cards and instructions for specimen collection and return. You should report the specimen analysis with 82270.

Extra: Sometimes, your choices don't end with the two current hemoccult codes (82270, 82272). Make sure you know the specific type of stool test for blood because you might also use the CPT code for immuno fecal occult blood testing (iFOBT), warns Weinstein. In this case, you would report 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations) for the iFOBT test, and the appropriate ICD-9 for the patient's symptoms. For routine colon cancer screening for Medicare patients, you would use G0328 (Fecal blood screening immunoassay) and V76.51.