Gastroenterology Coding Alert

Question: We have recently performed a fecal transplant on a patient with Medicare. In the past, we have done with other carriers CPT® of 45378 and 44799 with a 59 modifier. I have also tried using 44705. Now with Medicare I know they have come out with the G0455, which I was under the impression was for the preparation on the physician side. I have sent this claim to Medicare the way I have to other carriers, but I can not get Medicare to look at this claim. I can not even get the colonoscopy part of procedure paid. Any suggestions regarding the way in which I can report this procedure so that we can get reimbursed?

Houston Subscriber

Answer: For Medicare, CMS has created a new HCPCS code for preparation of fecal microbiota. Code G0455 (Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen) includes the physician work for assessment of donors, preparation of fecal microbiota and instillation.

When this service is provided to a Medicare beneficiary, HCPCS code G0455 should be billed instead of code 44705 (Preparation of fecal microbiota for instillation, including assessment of donor specimen). In the Physician Fee Schedule Final (PFS) Rule for fiscal year (FY) 2013, CMS stated “Within Medicare, payment for the preparation of the donor specimen would only be made if the specimen is ultimately usedfor the treatment of a beneficiary as Medicare is not authorized to pay for any costs not directly related to the diagnosis and treatment of a beneficiary. Because of this policy, we believe it is appropriate to bundle the preparation and instillation into one payable HCPCS code.”

As 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, CMS has combined both the microbiota sample prep and instillation in the HCPCS code, G0455. So, you will only report this code and not report any additional code for the placement of the specimen