Pathology/Lab Coding Alert

Whether a fecal specimen is from a digital rectal exam (DRE) or not, CPT 2008 makes one thing clear -- you should only use 82272 for diagnostic testing.

Although the 82272 change aligns with Medicare rules and allows sampling-method flexibility for a diagnostic guaiac fecal occult blood test (FOBT), it raises even more questions about when to use G0394 -- a code that Medicare added just last year.

The new 82272 definition (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening) clarifies that you should only use this code for diagnostic tests, says Melanie Witt, RN, CPC-OGS, MA, a coding expert based out of Guadalupita, N.M.

Emphasis changed: The old 82272 definition (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, single specimen [e.g., from digital rectal exam]) emphasized the specimen-collection method -- DRE. But the new definition emphasizes the reason for the test -- other than colorectal neoplasm screening.

Don't miss: You can still use 82272 for DRE collections. According to CPT 2008 Changes: An Insider's View: "The inclusion of the phrasing -1-3- in the descriptor clarifies that 82272 is appropriately reported for assessment of either a single sample obtained from a digital rectal exam or for assessment of a three-test card prepared by the patient."

Screening code is different: If your lab performs a screening guaiac-based FOBT, you should continue to report 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]).

Don't miss the screening specimen requirement: You should not use 82270 for a DRE specimen. The code definition makes this clear by specifying "consecutive collected specimens," and beginning the parenthetic phrase with "i.e.," which means "that is," -- not "e.g.," which means "for example."

Here's the reason: Studies have shown that office-based, single-sample FOBT specimens have limited screening value.

CMS added 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]) to the FOBT coding mix last year, and experts are still scratching their heads about how to use the code.

"Code G0394 is clearly not a screening code because it's not on Medicare's screening list," Witt says. "But the definition is confusing because it refers to a -single determination- as well as -consecutive collection- cards."

Now that CPT 2008 changed 82272 to include either DRE or multiple-card specimens, G0394 seems to be even more of an orphan code.

CMS says this: Medicare's colorectal cancer screening policy does not include G0394, but the laboratory National Coverage Determination (NCD) for diagnostic FOBT tests does. "For instance, one CMS official told me that you could use G0394 for a diagnostic test if a patient is on high-risk meds that cause GI bleeding," says Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis.

But carriers say this: Despite those CMS guidelines, individual carriers may differ. For instance, some Aetna, Oxford and Blue Cross/Blue Shield plans list G0394 for colorectal cancer screening, while others such as Empire, Noridian and TrailBlazer list G0394 for diagnostic FOBT.

Bottom line: "Use G0934 as your individual carrier directs," Witt says.

If you code for a lab with a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA), you-re probably used to using modifier QW (CLIA waived test) with the codes you report.

Exception: You should not append modifier QW to 82270, 82272 or G0394. If you do so, your carrier might suspend the claim for manual review, possibly causing a delay in your payment.

If your lab performs an FOBT by a method other than peroxidase activity, you can't use the codes for guaiac tests (82270, 82272 and G0394). 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.

Do this: To report the immunoassay, list 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, 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, which states, "1-3 simultaneous determinations." 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).

For more on Medicare, see "Make Sure You-re Using the Right FOBT Coverage Rules" on page 38.