Gastroenterology Coding Alert

And learn how and when to use an ABN.

How to properly report fecal microbiota transplants (FMT) tends to create confusion among coders and billers. Thank you to Sharon Vergine, CPC, coding/billing specialist at Digestive Health Clinic, Idaho Endoscopy Center, LLC in Boise, Idaho for sharing her FMT coding challenges. Take a look at the question she sent Gastroenterology Coding Alert, then read on to see what our experts have to say.

“Our physician performed a fecal transplant procedure for a patient with clostridium difficile infection who hasn’t responded to other therapies. The physician documented that this was not a diagnostic procedure, because they only used the colonoscope to instill the fecal matter. Because we used the colonoscope, do we bill CPT^® 45378? The Medicare HCPCS code G0455 includes preparation of the materials as well as instillation, so that does not appear to be the right code to use.

Does this fall under the non-covered or statutorily excluded guidelines? If so, is it billable to Medicare? What CPT^® modifier should be used on the claim, and which CPT^® code should we put on the ABN?

Understand the Available Codes and What They Mean to Payers

Procedure refresh: An FMT is when the gastroenterologist transplants fecal bacteria from a healthy donor into the digestive tract of a patient whose native microbiota need replacement or repair. The procedure is done via colonoscopy, nasogastric (NG) feeding tube, esophagogastroduodenoscopy (EGD), or rectal enema.

Private payers: “For most commercial plans, you’ll use CPT^® code 44705 [Preparation of fecal microbiota for instillation, including assessment of donor specimen] for specimen preparation,” says Jessica Miller, CPC, CPC-P, CGIC, profee division coding manager at Ciox Health in Chattanooga, Tennessee. This code is generally used to report the work the gastroenterologist has done to develop and assess the microbiota sample in preparation for instillation into the patient’s digestive tract. “Instillation of microbiota is separately reported,” Miller continues. Which one you report depends on the gastroenterologist’s method:

• 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure))
• 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed [separate procedure])
• 44799 (Unlisted procedure, small intestine)

Note: CPT^® code 74283 (Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, meconium ileus)) is a viable enema code. However, the CPT^® guidelines instruct coders to use 44799 for fecal instillation by oro-nasogastric tube or enema.

Medicare: Medicare will not accept a claim with 44705. However, if the diagnosis code proves medical necessity, HCPCS Level II code G0455 (Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen) is the one Medicare will validate with reimbursement. In the definition for G0455, “assessment” refers to the variety of tests run on potential donor stool to make sure they’re suitable for use. It doesn’t refer to the simple thawing of a commercial sample before instillation through a scope. There is not a separate instillation code to report to Medicare as you would for some private payers. “CPT^® G0455 includes any method of instillation,” explains Miller.

Medical necessity: The Centers for Medicare & Medicaid Services (CMS) says that there is only one set of ICD-10 codes that proves medical necessity, and that’s A04.7-, which includes A04.71 (Enterocolitis due to Clostridium difficile, recurrent) and A04.72 (Enterocolitis due to Clostridium difficile, not specified as recurrent). CMS considers FMTs for other conditions to be investigational.

However, according to CGS Administrators, a Medicare Administrative Contractor (MAC) for CMS (https://www.cgsmedicare.com/partb/pubs/news/2015/0215/cope28449.html) that processes and pays claims for Medicare Parts A and B, “fecal bacteriotherapy or fecal microbiota transplant (FMT) may be considered medically necessary as a treatment for recurrent or relapsing Clostridium difficile infection (CDI) as indicated by a positive C. difficile toxin stool test.” The report would also require the situation fit one of the following:

• At least three episodes of mild to moderate CDI and failure of a 6-8-week taper with vancomycin with or without an alternative antibiotic (e.g. rifaximin, nitazoxanide), or
• At least two episodes of severe CDI resulting in hospitalization and associated significant morbidity, or
• Moderate CDI not responding to standard therapy (vancomycin) for at least a week, or
• Severe fulminant C. difficile colitis with no response to standard therapy after 48 hours.

Summary: Medicare might deem FMT medically necessary for the treatment of recurrent Clostridium difficile infection that hasn’t responded to other therapies. Medicare will accept A04.71 and A04.72 as diagnosis codes, but the above criteria must also be met.

Know Why and When to Get an ABN

Just in case the payer does not agree to pay for the FMT, you’ll want to consider obtaining an Advanced Beneficiary Notice (ABN) from the patient before performing the procedure.

“Since some payers do not cover it [FMT], I would still obtain ABNs and let the patient know upfront about potential costs if one of the approved diagnosis codes is not the reason for the procedure,” says Miller. This waiver of liability alerts CMS to automatically bill the patient, but also it offers a comprehensive breakdown for the patient, so that they understand the potential financial obligation and can, therefore, make a more informed decision about whether to proceed with the procedure.

Tip: Make the ABN as easy to read as possible. “Since [ABNs] are informing patients what particular service is in question and why it might not be covered, they should be in plain English and used for individual circumstances, not as a routine matter,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. Additionally, Medicare has rules about how an ABN should look. If it’s deemed difficult to read, hard to understand, is produced en masse and distributed to many patients, does not list the actual service, or is signed after the date of service, for example, the patient could appeal and end up not having to pay. Consult CMS (https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN) for a full list of requirements.

So in addition to wanting to maintain good relationships with the patient, it makes good financial sense to write up a solid, easy-to-understand ABN. Use layman term text descriptions instead of CPT^® and ICD-10 codes to describe procedures, services, diagnoses, and to outline the patient’s medical condition. Include estimates on service costs, and make sure the patient knows to select their preferred option and the sign the ABN. If the patient refuses to choose an option, you need to mark that down clearly so that Medicare doesn’t deny the form on account of it being incomplete or incorrect. Additionally, remember that the patient needs a copy of the signed form, but the original should be kept on file.

To access the most up-to-date form and instructions, visit the CMS website.

Modifier alert: You can append any of the ABN modifiers below depending on payer and situation:

• GA (Waiver of liability statement issued as required by payer policy, individual case)
• GX (Notice of liability issued, voluntary under payer policy)
• GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-medicare insurers, is not a contract benefit)
• GZ (Item or service expected to be denied as not reasonable and necessary).