(Reproduced by permission from Medicare Focus, February, 1998, pp. 31 - 34.)

Medicare Part A
Local Medical Review Policy
Blood Occult Test

Policy Number: A98-09

Description

Occult blood test is one that was developed in order to detect blood in the stool which may not be seen grossly.

Note:

It should be noted that Section 4104 of the Balanced Budget Act of 1997 provides for coverage of various colorectal screening examinations subject to certain coverage, frequency and payment limitations effective January 1, 1998. Screening fecal occult blood blood tests (G0107) are covered at a frequency of once every 12 months for beneficiaries who have attained age 50.

Type of Bill: 12X, 13X, 14X, 21X, 22X, 23X, 71X, 73X, 74X, 75X

Revenue Codes: 30X, 31X

Indications

For HCPCS Code 82270

Reimbursement will be made only when there are medical indications such as suspected GI bleeding or suspected cancer of the GI tract based on symptoms and clinical exam.

Diagnosis Codes for Coverage

Category:

Pathology and Laboratory; Chemistry

HCFA's National Policy

Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, section 1862(a)(7). This section excludes routine physical examinations.

Reason for Denial

For HCPCS Code G0107

Patient less than 50 years of age and greater than one test in a 12-month period.

Non-covered Diagnosis Codes

For HCPCS Code 82270

Any code not listed as a covered diagnosis code in the "Covered ICD-9-CM Codes" section in this policy.

Sources of Information

• Program Memorandum Intermediaries/Carrier, HCFA Pub. 60AB, Rev. AB97-24, December 1997
• Medicare Part B Local Medical Review Policy - Alabama
• Carrier Advisory Committee - Alabama
• Section 4104 Balance Budget Act (BBA) 1997

Documentation Required

For HCPCS Code 82270
Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.

If documentation is requested for review, submit the following:

• History and Physical;
• Physician orders/progress notes documenting medical necessity;
• Diagnosis;
• Exam results;
• Itemization of charges.

Coding Guides

If procedure is done for diagnostic reasons, 82270 should be billed with appropriate ICD-9-CM code.

When billing HCPCS code 82270 and G0107 the number of services will always be one, regardless of the number of specimens on a card or number of specimen cards given the patient. Payment of this service is for the complete test rather than the number of specimen cards returned when the services are medically necessary.

It would be expected that HCPCS code 82270 and G0107 would not be billed to Medicare until the test is actually completed.

When billing HCPCS code G0107 the beneficiary must have attained age 50; covered frequency is once every 12 months.

Approvals

This policy is being adapted from the Carrier policy. It does not represent the sole opinion of the Intermediary/Medical Director. This policy was developed in consultation with the medical community via the Carrier Advisory Committee.