Fecal transplants taken up by American Hospital Association in letter to HHS about Medicare/Medicaid

Interesting discussion of Fecal Transplants is this letter from the American Hospital Association to HHS about Medicaid / Medicare: Marilyn Tavenner September 6, 2013 Page 1 of 33 September 6 ...

Key text is below:

"FECAL MICROBIOTA TRANSPLANTATION
Fecal microbiota transplantation (FMT), also known as fecal bacteriotherapy, or human probiotic infusion, is a medical treatment for patients with Clostridium difficile (C. difficile) enteritis or ulcerative colitis. C. difficile infection occurs in patients who have been administered antibiotics for a long period of time. The antibiotics destroy important disease-fighting bacterial flora in the intestine. Fecal transplants are believed to restore the bacteria back to normal, and the patient can recover. The fecal transplant works by repopulating friendly flora in the infected intestines. The donated feces is screened for disease and then mixed with a saline solution to the consistency of a “milkshake.” FMT can be performed by various routes including nasogastric (NG) tube, nasojejunal tube, upper tract endoscopy (EGD), colonoscopically or by retention enema. However, based on an editorial published in the Journal of Clinical Gastroenterology (Volume 45, Number 8, September 2011), colonoscopic FMT is the preferred method for the vast majority of C. difficile infection patients, and if carried out early, may prevent development of severe infection.

Effective with the 2013 edition of the CPT manual, the American Medical Association developed the CPT code 44705 (Preparation of fecal microbiota for instillation, including assessment of donor specimen) that includes:

• development of the intestinal instillate for the recipient; and
• evaluation of the donor specimen, including the physician review of results of testing the donor’s specimen for infectious pathogens

The CPT manual instructions require that the actual instillation or fecal microbiota transplant be coded separately using CPT 44799 for either oro-nasogastric tube or enema. Additional instruction in the CPT manual identifies that all laboratory testing provided for the patient is to be reported separately. Based on this instruction and the intent of the CPT code 44705, this is an add-on or “list separately in addition to the primary procedure,” which would be the instillation procedure, e.g., the oro-nasogastric tube or enema.


By contrast, effective Jan. 1, 2013, CMS created HCPCS code G0455, Preparation with instillation of fecal microbiota by any method, including assessment of donor recipient, and assigned it to APC 00340, with a payment of $49.64. The payment for code G0455 appears only to cover the work related to the preparation of the donor fecal microbiota specimen, which may also include the review of the donor lab results for presence of pathogenic microbes. However, the payment does not appear to recognize the work to prepare the patient for the implantation or the instillation of the donor microbes, or the work performed and supplies consumed during the instillation procedure. The additional cost to perform this portion of the procedure would include the supplies, e.g., nasogastric tubes (approximately $5 each), enema tubes (approximately $25 each), other disposables including drapes, gloves, gowns (approximate cost of $20); the overhead expenses are not considered in these additional costs. In addition, if the microbiota instillation is performed via colonoscopy or EGD, the payment does not recognize the cost of the endoscopic procedure. This is demonstrated by the CPT codes and corresponding APC payments as follows:

• Using EGD as method of instillation: Loss of APC 0141 for EGD with code 43200, Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure), with a payment of $623.45 (minus Significant Procedure, Multiple Reduction, if performed with other procedures).
• Using colonoscopy as method of instillation: Loss of APC 0143 for colonoscopy with code 45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimens) by brushing or washing, with or without colon decompression (separate procedure), with a payment of $691.32 (minus Significant Procedure, Multiple Reduction, if performed with other procedures).

We recommend that CMS delete code G0455 and replace it with three new G codes:

1. Create a new G code for “Preparation of fecal microbiota with instillation by oro- nasogastric tube or enema, including assessment of donor recipient,” and place it in a more appropriate APC to include the costs of the supplies. We prefer that a new code be created (rather than revise existing code G4055) since the meaning of the code would be significantly different and would confuse any future data analysis if the same code would include different methods of instillation.
   
2. Create a second new G code for “Preparation of fecal microbiota with instillation by upper endoscopy, including assessment of donor recipient,” and place it in APC 0143, Level I Upper GI Procedures.
   
3. Create a third new G code for “Preparation of fecal microbiota with instillation by colonoscopy, including assessment of donor recipient,” and place it in APC 0141, Lower GI Endoscopy. "