Gastroenterology Coding Alert

Hint: Use additional code for instillation when reporting 44705.

If your gastroenterologist performs fecal bacteriotherapy as a treatment for Clostridium difficile infections, don’t forget to look at payer policies before you report the assessment and preparation of the fecal microbiota sample with the newly introduced CPT^®code 44705.

Check These Prep and Assessment Options

For fecal bacteriotherapy services reporting turn to two codes: one for the preparation and assessment of the fecal microbiota sample and the other for the instillation in the patient’s gut.

Use code 44705 (Preparation of fecal microbiota for instillation, including assessment of donor specimen) to cover your gastroenterologist’s work developing the microbiota sample that will be instilled in the patient’s digestive tract and for assessing the sample. “This service includes only the preparation prior to instillation, not the work to instill the fecal microbiota,” says Bridgette Martin, LPN, CPC, CGIC, Coding Specialist - Digestive Care Center, Evansville, Indiana. This includes results of testing for Clostridium difficile toxins in the donor stool, as well as serologic testing of the donor’s specimen for hepatitis A, B, and C viruses, HIV-1, HIV-2, and syphilis, prior to instillation.

Don’t Forget to Report Instillation Separately

In addition to reporting 44705, you’ll report an additional code, depending on the method your gastroenterologist uses to introduce the fecal sample in the patient’s digestive tract.

When your gastroenterologist uses colonoscopy to introduce the sample, you will also report 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) to report the instillation procedure. You will therefore use 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) if your gastroenterologist prefers upper EGD for instillation.

However, when your gastroenterologist uses a rectal enema, orogastric tube or a nasogastric tube for instillation, you will have to resort to using the unlisted code 44799 (Unlisted procedure, intestine). “A parenthetical note following 44705 instructs you to report 44799 for fecal instillation via oro-nasogastric tube or enema,” reminds Martin. CPT^® guidelines specify that you cannot use 74283 (Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction [e.g., meconium ileus]) with 44705. Instead, you will have to use 44799 instead of 74283 when your gastroenterologist introduces the fecal transplant sample with an enema.

Look For Alternate HCPCS Code For Medicare Patients

CMS will only reimburse for preparation and assessment of a fecal microbiota sample if the sample has been used in the treatment of the patient. So, in order to clear confusion and to prevent claims for samples that have been prepared but not used in a patient, CMS combines microbiota sample prep and instillation in the new HCPCS code, G0455 (Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen). “Medicare states G0455 can only be reported once, and only if the specimen is ultimately used for the treatment of the beneficiary,” says Martin. 

When your gastroenterologist performs a stool transplant to combat recurrent C. difficile infection in a Medicare patient, you will have to use G0455 instead of 44705 for the preparation of the sample and another code to report the instillation. “In a letter dated December 28, 2012, the AGA and the ASGE commented to CMS regarding CMS’ plan to devalue the work involved in both procedures,” informs Martin. “They argue that there is extensive work involved in assessing the patient and the potential donor, and one provider may perform that assessment while another provider instills the microbiota.  By bundling the payment, one physician will receive payment for their own services, as well as the services provided by the other physician.”

See Payer Policies Prior to Billing 44705

As many payers follow Medicare policies, check with your payers before you bill fecal bacteriotherapy. When your gastroenterologist performs stool transplant, you can use 44705 and another CPT^® code for the instillation if the payer policy provides coverage to 44705. For instance, some payers are allowing coverage for 44705 until May 2013. So look for payer guidelines prior to using 44705.

If the payer is following Medicare policies, check payer policy to see if you can report the procedure using G0455 to report both the preparation and the instillation of the sample.

Example: Your gastroenterologist decides to perform stool transplant on a patient suffering from C. difficile infection not responding to antibiotic treatment and other forms of treatment. He prepares a sample from the patient’s spouse for the transplant. He orders a thorough assessment of the stool sample prior to using upper EGD for the instillation.

If payer policy allows reporting 44705, you will report this code for the preparation and assessment of the sample and 43235 for instillation. If the patient is a Medicare patient, you will only report G0455.