How To Use CPT Code 81528

CPT 81528 is a colorectal cancer screening test that uses a stool sample to analyze DNA markers and fecal hemoglobin, providing a positive or negative result. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 81528.

1. What is CPT 81528?

CPT 81528 is a code used to report the Oncology (colorectal) screening test, which is a 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. This test is primarily used to screen asymptomatic patients for colorectal cancer by evaluating stool samples for blood and/or DNA segments shed from a colorectal tumor.

2. 81528 CPT code description

The official description of CPT code 81528 is: 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.

3. Procedure

  1. Collect a stool sample from the patient.
  2. Perform fecal hemoglobin test to detect blood in the fecal material, if present.
  3. Analyze the stool sample for the presence and amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3).
  4. Input the test results along with patient information into a computer program for algorithmic analysis.
  5. Report a positive or negative test result based on the algorithmic analysis.

4. Qualifying circumstances

Patients eligible to receive CPT code 81528 services are asymptomatic individuals who require colorectal cancer screening. The test is not intended for symptomatic patients or those with a known history of colorectal cancer, polyps, or other related conditions. It is also not recommended for patients with a family history of colorectal cancer or those at high risk due to genetic syndromes.

5. When to use CPT code 81528

It is appropriate to bill the 81528 CPT code when performing a colorectal cancer screening test on an asymptomatic patient to detect the presence of blood and/or DNA segments shed from a colorectal tumor. A positive result from this test would warrant further investigation, such as a colonoscopy, to confirm a cancer diagnosis.

6. Documentation requirements

To support a claim for CPT 81528, the following information must be documented:

  • Patient’s demographic information, including age, gender, and ethnicity.
  • Relevant medical history, including any family history of colorectal cancer or genetic syndromes.
  • Indication for the test, such as routine colorectal cancer screening for an asymptomatic patient.
  • Details of the stool sample collection, including date and method of collection.
  • Results of the fecal hemoglobin test and DNA marker analysis.
  • Algorithmic analysis results, reported as a positive or negative test result.

7. Billing guidelines

When billing for CPT code 81528, keep in mind the following guidelines:

  • Do not separately report the technical lab tests, as they are included in the MAAA code.
  • Medicare and some other payers may not accept MAAA codes and may require billing only the underlying test codes.
  • Use the unlisted MAAA code, 81599, only when there is no Category I or administrative code for a given MAAA test.
  • Do not report CPT 81528 in conjunction with 81275 or 82274.

8. Historical information

CPT 81528 was added to the Current Procedural Terminology system on January 1, 2016. There have been no updates since its addition.

9. Similar codes to CPT 81528

Five similar codes to CPT 81528 and how they differentiate are:

  • CPT 81525: Focuses on the analysis of 92 DNA markers for colorectal cancer, rather than 10.
  • CPT 81526: Involves the analysis of 74 DNA markers for breast cancer, not colorectal cancer.
  • CPT 81527: Analyzes 58 DNA markers for ovarian cancer, not colorectal cancer.
  • CPT 81529: Examines 50 DNA markers for prostate cancer, not colorectal cancer.
  • CPT 81530: Analyzes 42 DNA markers for lung cancer, not colorectal cancer.

10. Examples

Here are 10 detailed examples of CPT code 81528 procedures:

  1. A 50-year-old asymptomatic patient undergoes a routine colorectal cancer screening using CPT 81528.
  2. A 60-year-old patient with no family history of colorectal cancer receives a CPT 81528 screening test as part of their preventive care.
  3. An asymptomatic 55-year-old patient with a negative colonoscopy five years prior undergoes a CPT 81528 screening test.
  4. A 65-year-old patient with no personal history of colorectal cancer or polyps receives a CPT 81528 screening test.
  5. An asymptomatic 70-year-old patient undergoes a CPT 81528 screening test as part of their routine preventive care.
  6. A 58-year-old patient with no known genetic syndromes related to colorectal cancer receives a CPT 81528 screening test.
  7. An asymptomatic 62-year-old patient undergoes a CPT 81528 screening test as part of their routine colorectal cancer screening.
  8. A 67-year-old patient with no previous history of colorectal cancer or related conditions receives a CPT 81528 screening test.
  9. An asymptomatic 53-year-old patient undergoes a CPT 81528 screening test as part of their preventive care.
  10. A 75-year-old patient with no family history of colorectal cancer receives a CPT 81528 screening test as part of their routine preventive care.

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