The world of medical research is one of innovation,
imagination and infinite possibilities. The world of medical coding isn’t.
Coding exists to bring structure and order to the art and science of medicine.
To clearly define situations by what they are and are not so that they can be
reimbursed fairly and efficiently.
Occasionally, these two worlds collide. When an ordering
physician faced with an unusual medical problem decides on an unorthodox (but
research-informed) combination of tests or treatments, this can present quite a
challenge for the coder. It is at times such as these that communities of
coders, like the RBMA’s Coding Forum, really prove their value.
The RBMA Coding Forum has seen questions ranging across a
broad gamut, including how to code and bill imaging done on conjoined twins. Recently,
a member asked if it is possible to bill for a radiology department’s part in
fecal transplant procedures.
Although once rare, fecal microbiota transplants (FMT), as
they are officially known, are now done at hospitals across the nation. Research
findings support that FMT is effective in the treatment of C. difficile infection, and it is now being studied as a possible
treatment for many other conditions, including diabetes, ulcerative colitis and
Still, the treatment is new and not officially approved by
the U.S. Food and Drug Administration. The FDA allows its use under its
investigational new drug guidelines and a 2013 special guidance for the
treatment of C. difficile in patients
who have tried the standard therapies without result.
There is also no one standard way to perform a FMT, with
multiple ways of administering the fecal microbiota from the donor in use. One
of those ways is through a nasogastric tube, which is how the Coding Forum
member’s hospital radiology department became involved.
FMT patients would check into the Endoscopy Department and
then be sent to the Radiology Department for placement of the NG tube with
fluoroscopic guidance. But there is no official protocol for how to code such
situations, and even the American Gastroenterological Association is at a bit
of a loss. It
recommends 44799, the code for unspecified procedure lower intestine, for
situations where donor microbiota is administered by either oro-nasogastric
tube or enema. Of course, payers sometimes will not accept unspecified codes.
In addition, Medicare does not pay a separate fee for installing microbiota by
NG tube, according
to the American Gastroenterological Association.
However, there is one possible solution for departments
doing a large enough volume of NG tube placements for FMT that the cost of this
unreimbursed care becomes a concern. In Medicare patients, gastroenterologists
will sometimes require patients to sign an Advanced Beneficiary Notice form to
alert them that part of their treatment will likely not be covered by Medicare
and that they will need to be responsible for paying this cost. The ABN is
usually sought because Medicare does not cover the costs of screening donor fecal
specimens for FMT. However, it could be adjusted to also address other areas of
unreimbursed care in an FMT, including the Radiology Department’s work.
Have you encountered an unusual coding situation that left
you perplexed? Does your hospital department place NG tubes for FMT or perform
other more unusual procedures? Your peers on the RBMA Coding Forum may be able
to help. The RBMA’s forums are exclusive benefits for RBMA members. Learn more