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82274 Denial

Cindy Posted Mon 20th of May, 2019 13:03:14 PM
Our office received a denial from Blue Cross for the lab because these were done one day apart. The first one was positive but the patient wanted to do a repeat before going further for treatment. The 1st one 82274 billed 03/27/2019 and the 2nd one 82274 billed 03/27/2019. Blue Cross sent this response to my inquiry: Based on our review of the additional information submitted, we will not change the processing of the original claim for the following reason: According to our policy, which is based on CMS Policy, 82270 (Blood, occult, by peroxidase activity), 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay) or G0394 (Blood occult test) reported as individual tests on consecutive days will be denied. The billed service, 82274, was denied because it should be reported as a single-service, per our policy, which is based on CMS Policy. Should we have billed this differently? We tried sending records and they still denied. Any advice would be appreciated. THank you
SuperCoder Answered Tue 21st of May, 2019 03:36:28 AM

Hi Cindy,

The MUE for CPT 82274 is one. So, we cannot bill it twice in a day. As the dates mentioned above “The 1st one 82274 billed 03/27/2019 and the 2nd one 82274 billed 03/27/2019)” mentions the same date of service.

Also, if we see the full description of the CPT code 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations), it means this code already requires one to three consecutive stool samples, collected from digital rectal exam in a day. Feel free to ask for any further query.

Cindy Posted Tue 21st of May, 2019 06:43:44 AM
I'm sorry that should have been one was done 03/27/2019 and the 2nd one was done 03/28/2019 based on the patient wanting another one before seeing a specialist. See above for the rest of the scenario, is there some other way we can bill this? Cindy
SuperCoder Answered Wed 22nd of May, 2019 02:36:19 AM

Sometimes private payer may not find the test performed as a “medical necessity” that is

Test may be clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease;

But are: 1) Primarily for the convenience of the patient, physician, or other health care provider, and/or 2) More costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

As in the above scenario patient is requesting for repeat test and it is not by doctors refferal. 

In such scenario you may reach to your private payer policy. Hope it helps.

Cindy Posted Wed 22nd of May, 2019 06:00:35 AM
No this does not help. I have no idea what you are telling me. The private pay policy as stated in my original post follows Medicare. Does Medicare have a policy on the same test 82274 in two consecutive days?
SuperCoder Answered Thu 23rd of May, 2019 04:17:07 AM

Hi Cindy,

Please note how this test is performed:

The physician gives the patient test cards to acquire samples at home. The physician explains how to acquire samples. The service represented by 82274 requires one to three consecutive stool samples, which the patient must obtain from separate bowel movements. The patient takes the cards home and performs the test (three consecutive days of samples is the standard). The patient returns to the physician's office with the cards.

Let us assume date of service when patient receives card as 03/27/2019.

And date of return as 03/29/2019 as he has to collect three samples from three separate bowel movements, where (three consecutive days of samples is the standard).

Warning:  We cannot bill the patient when giving them the test cards. We can only bill when the specimen is returned. 

So, our date of service will be the last date of specimen collection 03/29/2019.

Important: Avoid unnecessary denials by keeping these codes straight: Medicare pays for a screening FOBT only once a year, but diagnostic FOBT every three months.

NOTE:

Medicare and many other payers provide coverage for just one screening fecal occult blood test per year for beneficiaries age 50 and older. If the clinician orders the immunoassay FIT test for screening, report the service to Medicare with code G0328, Colorectal cancer screening; fecal occult blood test, immunoassay, 1to 3 simultaneous determinations. Reserve 82274 for diagnostic FIT tests for Medicare beneficiaries. Other payers may allow 82274 for a test for screening or diagnostic purposes. 

Please feel free to ask for any further query.

 

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