ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB025

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Defines BCBSOK laboratory reimbursement criteria for fecal analysis related to diagnosis of intestinal dysbiosis and testing requirements/prior-to-FMT organism testing; applies to providers submitting claims to Blue Cross Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyFecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Policy CodePolicy CPCPLAB025

Change TypeCodes added and removedreimbursement wording clarified

Key ActionSubmit accurate documentation and use the updated code set when filing claims for pre‑FMT and fecal analysis testing.

Effective DateMar 1, 2024

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Added codes 82239, 82725, 82784, 83520, 83630, 87177, 87209, 87328, 87329, 87336.

Removed codes 87076, 87077, 87081, 87106.

Reimbursement Information revised for clarity and literature review performed.

Document updated with literature review and references revised (03/01/2024 and 11/01/2023).

9codes added

4codes removed

2024-03-01effective date

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Coverage Criteria for Fecal Analysis and FMT Testing

Procedure and Laboratory Codes

Listed procedure codesCPT | HCPCS | mixed

82239
82542
82705
82710
82715
82725
82784
83520
83630
83986

1–10 of 26

1/3

Updated laboratory and microbiology codesmixed

82239
82725
82784
83520
83630
87177
87209
87328
87329
87336

1–10 of 14

1/2

Policy update dates

Most recent policy effective/update date03/01/2024 (Document updated with literature review; reimbursement information revised for clarity)

Prior update date11/01/2023 (Document updated with literature review; reimbursement information unchanged)

Policy creation date11/01/2022 (New policy)

Provider Responsibilities and Pre-FMT Testing Guidance

Documentation Required

Documentation and claim submission responsibility

Providers are responsible for submission of accurate documentation and may be asked to provide additional records to support medical necessity and coding. Claims must be submitted using valid HIPAA-approved code sets and in accordance with industry coding guidelines (CPT, HCPCS, ICD-10, NDC, UB, CMS/NCCI edits, etc.). Claims are subject to code edit protocols and review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit any additional documentation.

Billing Rule

Pre-FMT testing reimbursement guidance

Prior to fecal microbiota transplant (FMT), certain fecal analyses may be reimbursable while others are not. Reimbursable tests before FMT may include culture for ESBL-producing Enterobacteriaceae, VRE, CRE, MRSA, Campylobacter, Shigella, and Salmonella; and NAAT for C. difficile, Campylobacter, Salmonella, Shigella, Shiga toxin-producing E. coli, Norovirus, Rotavirus, and SARS-CoV-2. NAAT for ESBL, VRE, CRE, MRSA, and other organisms not listed above is not reimbursable. Fecal analyses performed as diagnostic tests for intestinal dysbiosis, irritable bowel syndrome, malabsorption, or small intestinal bacterial overgrowth — including triglycerides, chymotrypsin, iso-butyrate/iso-valerate/n-valerate, meat and vegetable fibers, and long chain fatty acids — are not reimbursable. Providers should code and bill tests consistent with these distinctions and be prepared to supply supporting documentation.

Definitions and Evidence

Plan documents

Definition of Plan documents'Plan documents' include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Hierarchy in conflictsIf a conflict arises between a CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Provider contractsIf a conflict arises between a CPCP and any provider contract, the provider contract will govern.

BCBSOK discretionBCBSOK may use reasonable discretion interpreting and applying this policy and has full and final discretionary authority as provided under applicable plan documents.

Literature cited

Guideline — BSG/HIS on FMT

Billing Rule

Code additions and reimbursement clarification

Code additions and reimbursement clarification: this policy was updated to add laboratory codes and clarify reimbursement language. Effective 03/01/2024 the following codes were added and should be recognized for billing where applicable: CPT 82239, 82725, 82784, 83520, 83630, 87177, 87209, 87328, 87329, 87336. The following codes were removed and are no longer listed in the policy: 87076, 87077, 87081, 87106. Providers must submit claims using the appropriate, current CPT/HCPCS codes and may be asked to supply documentation to justify medical necessity. Claims submitted with removed or invalid codes may be denied or returned for correction.

Added CPT codes: 82239, 82725, 82784, 83520, 83630, 87177, 87209, 87328, 87329, 87336
Removed codes: 87076, 87077, 87081, 87106
Effective date for updates: 2024-03-01