MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

Number 2.04.508

Effective Date April 16, 2013

Revision Date(s) 04/08/13; 07/10/12; 04/10/12; 05/10/11; 04/13/10; 12/08/09; 10/14/08; 08/14/07; 11/11/05; 02/08/05; 10/16/03; 01/08/02

Replaces 2.04.26

Policy

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Fecal analysis, as a diagnostic test, for the evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption, or small intestinal overgrowth of bacteria is considered investigational for the following components:

  • Triglycerides;
  • Chymotrypsin;
  • Iso-butyrate, iso-valerate and n-valerate;
  • Meat and vegetable fibers;
  • Long-chain fatty acids;
  • Cholesterol;
  • Total short-chain fatty acids;
  • Levels of Lactobacilli, bifidiobacteria and E. coli and other "potential pathogens," including Aeromonas, Bacillus cereus, Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas, Salmonella, Shigella, S. aureus, Vibrio;
  • Identification and quantitation of fecal yeast (including C. albicans, C. tropicalis, Rhodotorula and Geotrichum);
  • N-butyrate;
  • Beta-glucuronidase;
  • pH;
  • Short-chain fatty acid distribution (adequate amount and proportions of the different short chain fatty acids reflect the basic status of intestinal metabolism);
  • Fecal secretory IgA.

Fecal Calprotectin

Fecal analysis for fecal calprotectin, as a stand-alone test, is considered medically necessary for the following:

  • For evaluation of patients with inflammatory bowel disease (IBD)
  • To identify patients with IBD

The specific CPT code for this diagnostic test is:

83993 Calprotectin, fecal

Fecal calprotectin testing is considered investigational in the diagnosis and management of all other intestinal conditions.

Related Policies

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2.01.01

Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Multiple Chemical Sensitivities)

2.04.502

Heavy Metals Testing

2.04.511

Fecal Microbiota Transplantation (FMT)

2.04.73

Intracellular Micronutrient Analysis

Policy Guidelines

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Other names used to report fecal analysis of intestinal dysbiosis:

  • Comprehensive digestive stool analysis
  • Fecal analysis, intestinal dysbiosis
  • Genova diagnostics, comprehensive digestive stool analysis
  • Great smokies diagnostic laboratory, comprehensive digestive stool analysis
  • Intestinal dysbiosis
  • Stool analysis, intestinal dysbiosis

The following CPT codes may be used to identify individual components of fecal analysis of intestinal dysbiosis:

82239 Bile acids, total

82492 Chromatography, quantitative, column; multiple analytes, single stationary mobile phase (used to test for short chain fatty acid)

82656 Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitative

82710 Fat or lipids, feces; quantitative (used to test for fecal triglycerides)

82715 Fat differential, feces, quantitative (used to test for fecal cholesterol)

82725 Fatty acids, nonesterified (used to test for long chain fatty acids)

82726 Very long chain fatty acids

83520 Immunoassay, for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified (used for eosinophil protein X)

83630 Lactoferrin, fecal; qualitative

83631 Lactoferrin, fecal; quantitative

83986 pH, body fluid, except blood (used to measure fecal pH)

83993 Calprotectin, fecal

84311 Spectrophotometry, analyte, not elsewhere specified (used twice, once each to test for stool B-glucuronidase and chymotrypsin)

87102 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates: other source, except blood (used for fecal culture for fungi)

87328 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; cryptosporidium

87329 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; giardia

87336 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Entamoeba histolytica dispar group

89160 Meat fibers, feces

Fecal analysis may also include other standard components such as:

82272 – 822744 fecal occult blood

87045-87046; 87075 stool culture

87177; 87209 stool parasitology

Description

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Intestinal dysbiosis may be defined as a state of disordered microbial ecology that is believed to cause disease, including conditions such as irritable bowel syndrome (IBS) and malabsorption. Laboratory analysis of fecal samples is proposed as a method of identifying individuals with intestinal dysbiosis.

Background

The concept of dysbiosis rests on the assumption that patterns of intestinal flora, specifically overgrowth of some microorganisms found commonly in intestinal flora, have an impact on human health. Symptoms and conditions attributed to dysbiosis include chronic intestinal disorders including irritable bowel syndrome (IBS), inflammatory or autoimmune disorders, food allergy, atopic eczema, unexplained fatigue, arthritis and ankylosing spondylitis, malnutrition or neuropsychiatric symptoms including autism, and breast and colon cancer. Leo Galland, MD, is a researcher who has focused his studies on dysbiosis, has proposed 4 patterns of dysbiosis:

Putrefaction

Putrefaction dysbiosis results from a diet high in fat and animal flesh and low in insoluble fiber, i.e., typical of Western-style diet. It is thought that, compared to normal patterns of intestinal flora, this diet produces an increased concentration of Bacteroides sp., and a decreased concentration of bifidiobacteria in stools. The increased concentration of Bacteroides sp. is thought to be associated with increased urease, ultimately leading to a rising fecal pH. Bacteroides sp. is also thought to be associated with increased beta-glucuronidase, which functions to deconjugate bile acids, which are thought to be toxic to the colonic epithelium, causing diarrhea. Increased levels of beta-glucuronidase may also impact estrogen metabolism.

Fermentation

A fermentation pattern of dysbiosis has been attributed to bacterial overgrowth. In mild cases, fermentation may be characterized principally by carbohydrate intolerance, manifested by abdominal distention, flatulence, diarrhea, constipation and feelings of malaise.

Deficiency

Antibiotic therapy or decrease in dietary fiber may result in relative deficiencies of normal fecal flora, including bifidiobacteria, lactobacillus, and Escherichia coli.

Sensitization

A sensitization pattern of dysbiosis has been characterized as an abnormal immune response to the endotoxins and antigens associated with normal intestinal flora.

Laboratory analysis of both stool and urine has been investigated as markers of dysbiosis. Reference laboratories specializing in the evaluation of dysbiosis may offer comprehensive testing of various aspects of digestion, absorption, microbiology, and metabolic markers. For example, Genova Diagnostics (1) offers a "Comprehensive Digestive Stool Analysis 2.0" that evaluates a stool sample for the following components:

Digestion

  • Triglycerides
  • Chymotrypsin
  • Iso-butyrate, iso-valerate, and n-valerate
  • Meat and vegetable fibers

Absorption

  • Long-chain fatty acids
  • Cholesterol
  • Total fecal fat
  • Total short-chain fatty acids

Microbiology

  • Levels of Lactobacilli, bifidobacteria, and E. coli and other "potential pathogens," including Aeromonas, Bacillus cereus, Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas, Salmonella, Shigella, Staphylococcus aureus, Vibrio
  • Identification and quantitation of fecal yeast (including Candida albicans, C. tropicalis, Rhodotorula and Geotrichum)

Metabolic Markers

  • N-butyrate (considered key energy source for colonic epithelial cells)
  • Beta-glucuronidase
  • pH
  • Short-chain fatty acid distribution (adequate amount and proportions of the different short-chain fatty acids reflect the basic status of intestinal metabolism

Immunology

  • Fecal secretory IgA (as a measure of luminal immunologic function)
  • Calprotectin

The comprehensive stool analysis package also includes a parasitology component.

Inflammatory Bowel Disease (IBD)

Inflammatory bowel disease (IBD) is a chronic inflammatory condition typically associated with the symptoms diarrhea, defecation urgency, and sometimes rectal bleeding and abdominal pain. The 2 main forms of IBD are Crohn’s disease (CD) and ulcerative colitis (UC). Noninvasive diagnosis of inflammatory intestinal disease is difficult because the clinical manifestation of intestinal disorders and colon cancer are relatively non-specific.

The measurement of fecal calprotectin as a stand-alone biochemical test is commonly used in the evaluation of patients with inflammatory bowel disease (IBD), including to identify patients for endoscopy. This test is indicated to aid in the diagnosis of inflammatory bowel disease (IBD) and to differentiate IBD from irritable bowel syndrome (IBS). An advantage of fecal calprotectin as a marker is that it has been shown to be stable in feces at room temperature for up to 1 week–leaving enough time for patients to collect samples at home and send them to a distant laboratory for testing. The test for fecal calprotectin is intended to be used in conjunction with other diagnostic testing and clinical considerations.

Regulatory Status

Genova Diagnostics is an accredited medical laboratory, certified by 6 separate health agencies, including the Centers for Medicare & Medicaid Services, which oversees clinical labs in the United States under the federal Clinical Laboratory Improvement Amendment (CLIA).

In March 2006, the PhiCal™ (Genova Diagnostics) quantitative ELISA test for measuring concentrations of fecal calprotectin in fecal stool was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. (1)

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations.

Benefit Application

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Due to the nonspecific nature of the CPT codes used to identify different components of fecal analysis, identification of these claims may require identification of those laboratories that specialize in analysis for the evaluation of intestinal dysbiosis. Because there are a limited number of laboratories that provide this type of fecal analysis, these services may be provided by out-of-area providers. In addition, review of these services may be approached through retrospective review looking for specific patterns of testing.

Rationale

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This policy was originally created in 2001 and was updated regularly with searches of the MEDLINE database. The most recent literature search was performed for the period December 2010 through January 2013 Following is a summary of the literature to date:

Establishing that fecal analysis to identify intestinal dysbiosis is beneficial would involve evidence that the net health outcome is better in patients with gastrointestinal symptoms who are managed with fecal analysis than in those managed without fecal analysis. No studies were identified in the initial literature review or during any of the literature searches for policy updates that compared health outcomes in individuals managed with and without fecal analysis to identify intestinal dysbiosis. There were also no studies on the accuracy of fecal analysis versus another method for diagnosing IBS, small intestine bacterial overgrowth or other conditions. Moreover, no studies were identified establishing diagnostic criteria for “intestinal dysbiosis” as a disorder.

The literature at the time of policy development included much discussion regarding the relationship between intestinal microflora and various disorders. The gastrointestinal symptoms attributed to intestinal dysbiosis (i.e., bloating, flatulence, diarrhea, or constipation) overlap in part with either IBS or small intestinal bacterial overgrowth syndrome. The diagnosis of irritable bowel syndrome is typically made clinically, based on a set of criteria referred to as the “Rome” criteria. The small intestine normally contains a limited number of bacteria, at least in comparison to the large intestine. Small intestine bacterial overgrowth may occur due to altered motility (including blind loops), decreased acidity, and exposure to antibiotics, or surgical resection of the small bowel. Symptoms include malabsorption, diarrhea, fatigue, and lethargy. Although the diagnosis of bacterial overgrowth may be made clinically and the condition treated empirically with antibiotics, the laboratory gold standard for diagnosis consists of culture of a jejunal fluid sample. Recently, hydrogen breath tests, commonly used to evaluate lactose intolerance, have been adapted for use in diagnosing both small intestinal bacterial overgrowth and IBS.

Measurements of fecal fat (i.e., qualitative, quantitative, and fat differential) are established diagnostic techniques for malabsorption. In contrast, a literature search did not identify any published studies regarding the diagnostic performance of fecal analysis of digestion, absorption, microbiology, metabolic markers, or immunology as a workup of malabsorption syndrome, small intestine bacterial overgrowth, or intestinal dysbiosis. Chronic intestinal candidiasis has been linked with various gastrointestinal complaints as well as systemic complaints, such as chronic fatigue syndrome. However, similar to intestinal dysbiosis, chronic intestinal candidiasis is an ill-defined condition without established diagnostic parameters.

Several studies identified in literature updates compared microbiota in patients with known disease and healthy controls in an attempt to identify a microbiotic profile associated with a particular disease. None of these studies evaluated whether fecal analysis in patients with IBS or other conditions leads to improved health outcomes. All of the studies were conducted outside of the United States and used quantitative real-time polymerase chain reaction (PCR) analysis.

Representative studies are described below.

A 2012 study from Japan compared the fecal microbiota profiles of 161 patients with Crohn’s disease (CD) and 121 healthy controls. (2) Healthy individuals tended to have a different distribution of fecal microbiota than Crohn’s disease patients. For example, compared to controls, Crohn’s disease patients had significantly lower levels of Faecalibacterium, Eubacterium and significantly higher levels of Steptococcus.

A 2011 study by Sobhani and colleagues in France evaluated fecal microbiota samples taken prior to colonoscopy from 60 patients with colorectal cancer (CRC) and 119 gender-matched healthy individuals. (3) Total bacteria levels did not differ significantly between the colorectal cancer and non-colorectal cancer groups. There were significant elevations of the Bacteriodes/Prevotella group in the colorectal cancer population.

In 2011, Joossens and colleagues in Belgium published a study comparing fecal microbiota in 68 patients with Crohn’s disease, 84 unaffected relatives and 55 matched controls. (4) When samples from patients with Crohn’s disease were compared to all unaffected controls, significant differences were found in the concentration of 5 bacterial species. Compared to controls, Crohn’s disease patients had lower levels of Dialister invisus, an uncharacterized species of Clostridium cluster XIVa, Faecalibacterium prausnitzii and Bifidobacterium adolescentis and an increase in Ruminococcus gnavus.

In addition, several studies have evaluated whether fecal markers can distinguish between individuals with various gastrointestinal diseases. (5-9) The studies have included patients with known disease; none evaluated fecal analysis for the diagnosis of patients with chronic intestinal symptoms and without an established diagnosis. For example, Langhorst and colleagues in Germany evaluated 139 patients (54 irritable bowel syndrome [IBS], 43 Crohn’s disease [CD], 42 ulcerative colitis [UC]) undergoing diagnostic ileocolonoscopy, which provided fecal samples. (7) Samples were analyzed with enzyme-linked immunosorbant assay (ELISA). Patients with UC or CD and active inflammation had significantly higher levels of lactoferrin, calprotectin, and polymorphonuclear-elastase compared to patients with inactive inflammation as well as patients with IBS (all p<0.05). In patients with UD and CD, there were higher levels of all 3 markers in those with inflammation compared to those without inflammation.

A 2009 review article by researchers at McMaster University in Canada states that current understanding of how intestinal microbiota interact with the host and affect the expression of gastrointestinal tract and other systemic diseases is still in its infancy. (10) They recommend further research into correlations between microbiota profiles and symptoms in chronic conditions such as IBS.

A number of published studies evaluate the sensitivity and specificity of fecal calprotectin testing for diagnosing inflammatory bowel disease (IBD), the FDA-approved indication for the fecal calprotectin test. In 2010, van Rheenen and colleagues published a meta-analysis of diagnostic accuracy studies.(11) In the adult studies, the pooled sensitivity and specificity of the fecal calprotectin test for distinguishing between IBD and non-IBD was 93% (95% confidence interval [CI]=85% to 97%) and 96% (95% CI=79% to 99%), respectively. For children and teenagers, the corresponding numbers were a sensitivity of 92% (95% CI=84% to 96%) and specificity of 76% (95% CI=62% to 86%). Specificity was significantly lower in children and teenagers than in adults, p=0.048. The authors did not recommend use of the test to screen asymptomatic patients and did not recommend use of the test in a primary care setting.

Comito and Romano published an article after a systematic review of the literature stating that Inflammatory bowel diseases (IBDs) are chronic inflammatory conditions of the gastrointestinal tract that occur in genetically susceptible individuals. Both Crohn's disease (CD) and ulcerative colitis (UC) are major types of IBD. In approximately 20-25% of patients, disease onset is during childhood and pediatric IBD can be considered the best model for studying immunopathogentic mechanisms. A condition of "dysbiosis", with alterations of the gut microbial composition, is considered to be the basis of IBD pathogenesis. This pathogenesis is considered a defective innate immunity and bacterial killing with an overaggressive adaptive immune response The human gastrointestinal (GI) microbial population is a complex, dynamic ecosystem and consists of up to one thousand different bacterial species. In healthy individuals, intestinal microbiota has a symbiotic relationship with the host organism and carries out important metabolic, "barrier," and immune functions. Microbial dysbiosis in IBD with lack of beneficial bacteria, together with genetic predisposition, is the most relevant conditions in the pathogenesis of the pediatric IBD. (12)

 

Another area of research is the effectiveness of probiotics for treating patients with irritable bowel syndrome (IBS). Presumably, if probiotics improve symptoms, then some degree of intestinal dysbiosis had been present. A number of meta-analyses have been published on the efficacy of probiotic treatment for IBS (13-17). In 2012, Jonkers and colleagues conducted a systematic review of studies evaluating probiotics in the management of IBS. (17) Overall, the authors identified few well designed RCTs and only a limited number of trials suitable for meta-analysis. The pooled analyses did not find statistically significant benefits associated with probiotics compared to placebo or standard care. Moreover, none of the trials identified in the systematic reviews were reported to use fecal analysis as part of its diagnostic or treatment protocols.

Summary

Laboratory analysis of fecal samples is proposed as a method of identifying individuals with intestinal dysbiosis (defined as a state of disordered microbial ecology). There is insufficient evidence that fecal analysis to identify intestinal dysbiosis improves the net health outcome in patients with gastrointestinal symptoms. Moreover, there is insufficient evidence that fecal analysis aids in the diagnosis or management of patients with irritable bowel syndrome, malabsorption or small intestine bacterial overgrowth.

There is insufficient literature that shows fecal calprotectin testing improves health outcomes in patients without a high clinical suspicion of having inflammatory bowel disease (IBD) as demonstrated by bowel symptoms plus evidence of generalized inflammation such as elevated erythrocyte sedimentation rate. Therefore, fecal calprotectin testing is considered investigational in the diagnosis and management of all other intestinal conditions. 

Practice Guidelines and Position Statements

None identified.

Medicare National Coverage

There is no national coverage determination.

References

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  1. Genova Diagnostics. URL address: http://www.gdx.net/ . Last accessed March 15, 2013.
  2. Andoh A, Kuzuoka H, Tsujikawa T et al. Multicenter analysis of fecal microbiota profiles in Japanese patients with Crohn's disease. J Gastroenterol 2012; 47(12):1298-307.
  3. Sobhani I, Tap J, Roudot-Thoraval F et al. Microbial dysbiosis in colorectal cancer (CRC) patients. PLoS One 2011; 6(1):e16393.
  4. Joossens M, Huys G, Cnockaert M et al. Dysbiosis of the faecal microbiota in patients with Crohn’s disease and their unaffected relatives. Gut 2011; 60(5):631-7.
  5. Rajilic-Stojanovic M, Biagi E, Heilig HG et al. Global and deep molecular analysis of microbiota signatures in fecal samples from patients with irritable bowel syndrome. Gastroenterology 2011; 141(5):1792-801.
  6. Rinttila T, Lyra A, Krogius-Kurikka L et al. Real-time PCR analysis of enteric pathogens from fecal samples of irritable bowel syndrome subjects. Gut Pathog 2011; 3(1):6.
  7. Langhorst J, Elsenbruch S, Koelzer J et al. Noninvasive markers in the assessment of intestinal inflammation in inflammatory bowel diseases: performance of fecal lactoferrin, calprotectin, and PMN-Elastase, CRP and clinical indices. Am J Gasteroenterol 2008; 103(1):162-9.
  8. Otten CM, Kok L, Witteman BJ et al. Diagnostic performance of rapid tests for detection of fecal calprotectin and lactoferrin and their ability to discriminate inflammatory from irritable bowel syndrome. Clin Chem Lab Med. 2008;46(9):1275-80.
  9. Schoepfer AM, Trummler M, Seeholzer P et al. Discriminating IBD from IBS: comparison of the test performance of fecal markers, blood leukocytes, CRP, and IBD antibodies. Inflamm Bowel Dis. 2008;14(1):32-39.
  10. Collins SM, Denou E, Verdu EF et al. The putative role of the intestinal microbiota in the irritable bowel syndrome. Dig Liver Dis 2009; 41(12):850-3.
  11. van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ 2010; 341:c3369.
  12. Comito D, Romano C. Dysbiosis in the pathogenesis of pediatric inflammatory bowel diseases. Int J Inflam. 2012;2012:687143. doi: 10.1155/2012/687143. Epub 2012 May 20.
  13. McFarland LV, Dublin S. Meta-analysis of probiotics for the treatment of irritable bowel syndrome. World J Gastroenterol 2008; 14(17):2650-61.
  14. Wilhelm SM, Brubaker CM, Varcak EA, et al. Effectiveness of probiotics in the treatment of irritable bowel syndrome. Pharmacotherapy 2008; 28(4):496-505.
  15. Nikfar S, Rahimi R, Rahimi F, et al. Efficacy of probiotics in irritable bowel syndrome: a meta-analysis of randomized, controlled trials. Dis Col Rectum 2008; 51(12):1775-80.
  16. Hoveyda N, Heneghan C, Mahtani KR et al. A systematic review and meta-analysis: probiotics in the treatment of irritable bowel syndrome. BMC Gastroenterol 2009; 9:15.
  17. Jonkers D, Penders J, Masclee A et al. Probiotics in the management of inflammatory bowel disease: a systematic review of intervention studies in adult patients. Drugs 2012; 72(6):803-23.
  18. BlueCross BlueShield Association Medical Policy Reference Manual Fecal Analysis in the Diagnosis of Intestinal Dysbiosis. Medical Policy Reference Manual, Policy No. 2.04.26, 2012.
  19. BlueCross BlueShield Association Medical Policy Reference Manual “Fecal Calprotectin Testing”. Medical Policy Reference Manual, Policy No. 2.04.69, 2012.
  20. U.S. Food and Drug Administration (FDA). PhiCal 510(k) Substantial Equivalence Determine Decision Summary. Last accessed March 15, 2013.

Coding

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Codes

Number

Description

CPT

82239

Bile acids, total

 

82270

Blood, occult, by peroxidase activity (e.g., guaiac) qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)

 

82491

Chromatography, quantitative, column (e.g., gas liquid or HPLC).; single analyte not elsewhere specified single stationary and mobile phase

 

82492

Chromatography, quantitative, column; multiple analytes, single stationary and mobile phase (used to test for short chain fatty acids)

 

82656

Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitative

 

82710

Fat or lipids, feces; quantitative

 

82715

Fat differential, feces, quantitative

 

82725

Fatty acids, nonesterified

 

82726

Very long chain fatty acids

 

83520

Immunoassay, for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified (used for eosinophil protein X)

 

83630

Lactoferrin, fecal; qualitative

 

83631

Lactoferrin, fecal; quantitative

 

83986

pH, body fluid, not otherwise specified

 

83993

Calprotectin, fecal

 

84311

Spectrophotometry, analyte not elsewhere specified (used twice, once each to test for stool B-glucoronidase and chymotrypsin)

 

87045

Culture, bacterial; stool, aerobic with isolation and preliminary examination (e.g., KIA, LIA), Salmonella and Shigella species

 

87046

Stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate

 

87102

Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood)

 

87177

Ova and parasites, direct smears, concentration and identification

 

87328

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; cryptosporidium

 

87329

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; giardia

 

87336

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Entamoeba histolytica dispar group

 

89160

Meat fibers, feces

ICD-9 Procedure

   

ICD-9 Diagnosis

   

ICD-10-CM (effective 10/1/14)

   

ICD-10-PCS

(effective 10/1/14)

   

HCPCS

   

Type of Service

Pathology/
Laboratory

 

Place of Service

Outpatient

 

Appendix

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N/A

History

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Date

Reason

01/08/02

Add to Medicine Section - New Policy

10/16/03

Replace Policy - Policy reviewed with literature review. No change in policy statement. Retitled to make more user-friendly.

02/08/05

Replace Policy - Policy reviewed with literature review; no change in policy statement; title change from “Fecal or Stool Analysis.”

11/11/05

Replace Policy - Policy updated with literature review; no change to policy statement.

02/06/06

Codes updated - No other changes.

06/16/06

Codes Updated - No other changes

02/23/07

Codes Updated - No other changes.

08/14/07

Replace Policy - Policy updated with literature review; references added. No change in policy statement.

11/12/07

Code updated - CPT code 89225 deleted as a result of RPIW.

10/14/08

Replace Policy - Policy updated with literature search; no change to the policy statement. References added.

12/08/09

Replace Policy - Policy updated with literature search; no change to policy statement.

04/13/10

Replace Policy - Policy updated with literature search; Lactoferrin and starch granules removed from policy statement; no other change to policy statement. Rationale section extensively rewritten. References added.

05/10/11

Replace Policy - Policy updated with literature review; Reference numbers 6-8 added; reference 4 updated; other references renumbered. No change in policy statement. Codes added.

09/19/11

Codes 82726 and 83631 added to policy; Policy Guidelines updated.

04/25/12

Replace policy. Policy updated with literature review. References 1, 3-6 added; other references renumbered. No change in policy statement.

07/10/12

New policy replacing 2.04.26. New policy statement added: Fecal calprotectin as a stand-alone test used in the evaluation of patients with inflammatory bowel disease (IBD), including to identify patients for endoscopy; is considered medically necessary. Fecal calprotectin testing is considered investigational in the diagnosis and management of all other intestinal conditions. (Fecal calprotectin was previously considered investigational in 2.04.69.) Description and Rationale sections revised. Reference 11 added. Related Policy 2.04.69 archived and removed. Related Policies Update – Title to 2.01.01 has been changed to include: (i.e., Multiple Chemical Sensitivities)

09/18/12

Update Coding Section – ICD-10 codes are now effective 10/01/2014.

04/16/13

Replace policy. Policy & Policy Guidelines sections reformatted for readability. Rationale section updated based on literature review through February 2013. References 2, 12, 17 added; others renumbered or removed. Policy statement unchanged.

10/18/13

Update Related Policies. Add 2.04.511.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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