Leverage Vital Q/A for Optimal Colorectal Cancer Screening Reporting

By: Elizabeth

If coding your colorectal cancer screening claims has you confused, our experts can help. With an increasing number of colorectal lab tests that physicians use to assess a patient for colorectal cancer (CRC), we’ve received an influx of questions from path/lab coders like you. That’s why we’ve asked Ellen Garver BS, BA, CPC, to address … Continue reading Leverage Vital Q/A for Optimal Colorectal Cancer Screening Reporting

If coding your colorectal cancer screening claims has you confused, our experts can help.

With an increasing number of colorectal lab tests that physicians use to assess a patient for colorectal cancer (CRC), we’ve received an influx of questions from path/lab coders like you. That’s why we’ve asked Ellen Garver BS, BA, CPC, to address some of the more common questions.

Master your understanding of this complicated topic — and prevent coding errors from siphoning off your well-earned pay — by reviewing the following questions and answers.

Question 1: Distinguish Stool Tests

How should we code a screening test for occult blood in a fecal specimen?

Answer: CPT® provides one code for this screening test: 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)).

Attention: Notice that the specimen is three consecutively collected feces samples.

Diagnosis: Because this is a screening test, the appropriate diagnosis code would be Z12.11 (Encounter for screening for malignant neoplasm of colon) or Z12.12 (Encounter for screening for malignant neoplasm of rectum).

Caution: Do not report the following related codes for the fecal screening test:

  • 82271 (… other sources). Use this code for other-source specimens, such as vomit.
  • 82272 (Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening).

Although the lab test and specimen source are the same for codes 82270 and 82272, you should use 82272 only for a diagnostic test. That means you should reserve 82272 for fecal specimens taken when the patient has signs or symptoms, including a single fecal specimen taken during a digital rectal exam (DRE).

Immunoassay is different: Although all FOBTs used to be guaiac-based, newer tests identify occult blood in a fecal specimen using immunoassay techniques. You might see this test called Immunochemical FOBT, Immunoassay FOBT, iFOBT, or FIT (fecal immunochemical test).

Clinicians may prefer the FIT procedure over FOBT, both for accuracy and to avoid possible complicating factors, such as meat consumption or rectal bleeding that can interfere with guaiac test results.

You have the following two codes to choose from for the FIT test:

  • 82274 (Blood, occult, by fecal hemoglobin determi¬nation by immunoassay, qualitative, feces, 1-3 simultaneous determinations)
  • G0328 (Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous).

Caution: For Medicare and many other payers, you should report G0328 for the screening test, and reserve 82274 for a diagnostic FIT test ordered based on signs or symptoms.

Question 2: Recognize Molecular Tests

Are there any genetic tests recommended for colorectal cancer (CRC) screening? If so, what are they?

Answer: Two clinical lab tests have at least a component that evaluates DNA markers for CRC in a patient specimen.

Cologuard®: One of the tests uses both a standard FIT stool test and a molecular diagnostics test to interrogate 10 DNA markers in the stool specimen. The assay includes an algorithmic calculation to predict possible CRC based on the results of both tests. The commercial test is called Cologuard®, and the code is 81528 (Oncology [colorectal] screening, quantitative real-time target and signal amplification of 10 DNA markers [KRAS mutations, promoter methylation of NDRG4 and BMP3] and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result).

Caution: You shouldn’t bill the FIT test (82274, Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations) in addition to the Cologaurd® test (81528).

Although the Cologuard® test is more sensitive than FIT alone, it has a lower specificity, introducing the potential for false positives leading to more colonoscopies.

Medicare has developed a policy to pay for this test as a screening tool in certain circumstances. The patient must meet these criteria for coverage:

  • The patient is between 50–85 years of age
  • Patient shows no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive fecal occult blood test
  • Patient is not at high risk for developing colorectal cancer, meaning no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease (including Crohn’s Disease and ulcerative colitis)
  • Patient has no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.

SEPT9: Another clinical lab test that evaluates CRC genetic markers is the blood test for SEPT9 gene methylation assay. This is the first FDA-approved blood test for colorectal cancer screening.

Although the US Preventive Services Task Force (USPSTF) included this test in the screening recommendation statement for average risk patients at least 50 years old, the statement reported the test to have low sensitivity (48 percent) for detecting CRC.

Question 3: Focus on Tier 1 Codes

Our lab performed a Buccal Colaris genetic test for a patient based on a family history of colon cancer. Is this a CRC screening test, and how should we code it?

Answer: No, Colaris®, which is test by Myriad Genetics, Inc., is not a screening test for CRC.

Instead, tests such as Colaris® are genetic tests to assess a person’s risk of developing hereditary CRC, such as Lynch Syndrome (also known as hereditary nonpolyposis colorectal cancer or HNPCC), familial adenomatous polyposis (FAP), and MYH-associated polyposis (MAP).

The tests typically use a blood specimen or buccal (oral) swab specimen and involve DNA sequencing analysis of several genes, such as MLH1, MSH2, MSH6, and PMS2.

Correct coding for the tests involves selecting the codes for the specific gene mutations interrogated, such as the following codes:

  • 81292 (MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis)
  • 81288 (… promoter methylation analysis)
  • 81293 (… known familial variants)
  • 81294 (… duplication/deletion variants)
  • 81295 (MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis)
  • 81296 (… known familial variants)
  • 81297 (… duplication/deletion variants)
  • 81298 (MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis full sequence analysis)
  • 81299 (… known familial variants)
  • 81300 (… duplication/deletion variants)
  • 81301 (Microsatellite instability analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg BAT25, BAT26) includes comparison of neoplastic and normal tissue, if performed)
  • 81317 (PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis)
  • 81318 (… known familial variants)
  • 81319 (… duplication/deletion variants).

Contributing Editor: Ellen Garver

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The Coders’ Specialty Guide 2019: Pathology/ Laboratory includes all CPT® and HCPCS codes relevant to pathology, simple descriptions that explain each code, expert advice for assigning codes, Medicare reimbursement details, diagnosis codes crosswalk, applicable modifiers, CCI edits, global days, code index, hundreds of anatomical illustrations, and more.

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