Reducing Costs

Not surprisingly, the high costs associated with C. diff are a major issue within hospitals. The Agency for Healthcare Research and Quality found that from 1993 to 2009, the overall costs for C. diff hospital stays were 2.3 percent of the total hospital costs nationwide or $8.2 billion dollars (approximately $24,400 on average per individual stay). Costs nearly triple from $10,100 to $31,500 when C. diff is the secondary diagnosis, due to longer hospital stays (16.0 days in a secondary diagnosis versus 6.9 days for primary diagnosis).

The agency also reported, “most C. diff hospital stays (67.9 percent) were covered by Medicare, 18.8 percent of stays were privately insured, 9.1 percent were covered by Medicaid, and 2.3 percent were uninsured” (Lucado et al, 2012, p.3).

The majority of the costs associated with C. diff for the hospitals are related to the extent of the patient’s time in the hospital, including long term stay and treatment in the ICU for severe cases. In a 2012 study of “500 patients diagnosed with Clostridium difficile infection on admission or during hospitalization, 12.4% were cared for in an intensive care unit, and half of these required isolation” (Walsh, 2014).

Readmission rates for C. diff further add to hospital costs. In a 2012 study from Murphy and coworkers, post discharge C. diff hospital readmissions consisted of 2,998 (out of 170,995) or 1.8 percent of these occurrences. The majority of these were within the first 4-12 weeks post discharge, raising the question of effective treatment and prevention strategies (Murphy et al, 2012).


Cost of antibiotic therapy for C. diff infection

 

Cost per dose

Regimen

Cost per 10-day regimen

Metronidazole 500 mg

$0.73

500 mg three times a day

$22.00

Vancomycin 125 mg pills

$17.00

125 mg four times a day

$680.00

Vancomycin 125 mg 
IV compounded for oral

$2.50–$10.00

125 mg four times a day

$100.00–$400.00

Fidaxomicin 200 mg

$140.00

200 mg twice a day

$2,800.00

 

From a reimbursement model, CMS has identified limited CPT codes for billing FMT. The Ethicon 2013 Upper GI/Colonoscopy Reimbursement Fact Sheet lists the CPT codes for FMT and their descriptions.

Private payers only:

  • 44705- Preparation of fecal microbiota for instillation, including assessment of donor specimen.
    • Average reimbursement for code 44705 is $115
  • 44799- Instillation of FMT via Oro-Nasogastric tube or Enema
    • Average reimbursement for 44799 (TBD)
  • 43259-  Instillation of FMT via Esophagogastroduodenoscopy (EGD)
    • Average reimbursement for 43259 is $307 Facility, TBD for Non Facility
  • 45383 or desired code for Colonoscopy- Instillation of FMT via Colonoscopy
    • Average reimbursement for 45383 is $341 Facility and $591 Non Facility

Medicare beneficiaries have a separate HCPCS code for FMT and they combine the preparation and the instillation together. Medicare does not pay a separate fee for the instillation of the microbiota by oro-nasogastric tube, enema, or upper/lower endoscopy.

Medicare beneficiaries only:

  • HCPCS code G0455- Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen is used.
    • CMS has assigned a total RVU for HCPCS code G0455 at 3.55 (AGA, 2014)