(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.

CPT/HCPCS Codes: 82270 Blood, occult; feces, 1-3 simultaneous determinations
G0107 Colorectal cancer screening, fecal occult blood test, 1-3 simultaneous determinations.


Diagnosis Codes for Coverage

82270 One of the following covered ICD-9-CM diagnosis codes must be linked to the appropriate procedure.


ICD-9-CM Code Description
V10.00 - V10.09
V12.71
V12.72
V12.79
Persons With Potential Health Hazards Related to Personal and Family History



150.0 - 150.9
151.0 - 151.9
152.0 - 152.9
153.0 - 153.9
154.0 - 154.8
Malignant Neoplasm of Digestive Organs and Peritoneum




211.0 - 211.9
228.09
Benign Neoplasms

230.2 - 230.9 Carcinoma in Situ
235.2 - 235.5 Neoplasms of Uncertain Behavior
280.0
284.0 - 284.9
285.1 - 285.9
Diseases of the Blood and Blood-Forming Organs


456.0 Diseases of Veins and Lymphatics, and Other Diseases of Circulatory System
530.10 - 530.19
530.2
530.7
530.12 Revised per Medicare Focus December, 2001
531.00 - 531.01
532.40 - 532.41
533.30 - 533.31
533.40 - 533.41
534.00 - 534.01
534.40 - 534.41
535.00 - 535.01
535.00 - 535.01
535.50 - 535.51
Diseases of Esophagus, Stomach, and Duodenum











550.0 - 555.9
556.0
557.0 - 557.9
558.1 - 558.9
Noninfectious Enteritis and Colitis



562.10 - 562.11
569.3
Other Diseases of Intestines and Peritoneum

578.0 - 578.9 Other Diseases of Digestive System
780.71-780.79
783.21 Revised per Medicare Focus December, 2000
789.00 - 789.09
Symptoms
Revised per MedicareFocus, September, 1999


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


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:


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.

Start Date of Comment Period: August, 1995
Start Date of Notice Period: January 1, 1997
Effective Date: March 1, 1997
Revision Date: January 1, 1998
Revision Number: A98-09