# Capsule Endoscopy _Medicare



## cpc05 (Nov 20, 2012)

Has anyone been getting denials from Medicare stating that the procedure is not medically necessary when billing CPT 91110 with dx code 281.0? We have recently started getting denials when these codes billed together. Any suggestions?


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## Grintwig (Nov 20, 2012)

281.0 pernicious anemia does not meet medical necessity per LCD number L31800. 



*LCD Information 

Document Information 



LCD ID Number 
L31800 

LCD Title 
Wireless Capsule Endoscopy 

Contractor's Determination Number 
L6330 

AMA CPT/ADA CDT Copyright Statement 
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 
 Primary Geographic Jurisdiction  
North Carolina
South Carolina
Virginia
West Virginia

Oversight Region
Region IV


Original Determination Effective Date 
For services performed on or after 03/19/2011 

Original Determination Ending Date 


Revision Effective Date 
For services performed on or after 06/18/2011 

Revision Ending Date 





CMS National Coverage Policy 

Indications and Limitations of Coverage and/or Medical Necessity

Wireless capsule endoscopy (WCE) is a non-invasive diagnostic imaging procedure utilizing a miniature digital video camera contained in a non-biodegradable capsule. The capsule is swallowed and images are transmitted by radio-telemetry to external sensors worn by the patient, where they are stored for later review and interpretation. 

Indications

WCE is indicated for the evaluation of gastrointestinal blood loss of obscure origin, or anemia due to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the esophagus, stomach, duodenum, (EGD), and colon (colonoscopy) by conventional instrumental endoscopy. 
WCE is also indicated as a primary procedure in the evaluation of signs or symptoms suspected to be indicative of small bowel neoplasm or regional enteritis. As a primary procedure, prior EGD and colonoscopy are not a prerequisite for these indications.

Limitations

A physician trained in gastrointestinal endoscopic interpretation must interpret WCE.

WCE must be performed:

Under the general supervision of a physician trained in endoscopic interpretation. 


With a device approved by the FDA.

WCE is not covered for the following:

Patients with blood loss who have not been properly evaluated prior to WCE with conventional endoscopic procedures. 
Colorectal cancer screening or surveillance. 
Evaluation of hematemesis. 
Screening for esophageal disorders (Barrett's esophagus, varices) or portal hypertensive gastropathy.
Coding Information 

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 



Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.



99999 
 Not Applicable





CPT/HCPCS Codes 

CPT CODES

91110
 GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH PHYSICIAN INTERPRETATION AND REPORT

91111
 GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS WITH PHYSICIAN INTERPRETATION AND REPORT




ICD-9 Codes that Support Medical Necessity 






Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this policy have been met.

CPT Code 91110

152.0 - 152.9
 MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE

211.2
 BENIGN NEOPLASM OF DUODENUM JEJUNUM AND ILEUM

230.7
 CARCINOMA IN SITU OF OTHER AND UNSPECIFIED PARTS OF INTESTINE

235.2
 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM

280.0
 IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC)

280.9
 IRON DEFICIENCY ANEMIA UNSPECIFIED

285.1
 ACUTE POSTHEMORRHAGIC ANEMIA

457.1
 OTHER LYMPHEDEMA

537.82
 ANGIODYSPLASIA OF STOMACH AND DUODENUM (WITHOUT HEMORRHAGE)

537.83
 ANGIODYSPLASIA OF STOMACH AND DUODENUM WITH HEMORRHAGE

537.84
 DIEULAFOY LESION (HEMORRHAGIC) OF STOMACH AND DUODENUM

555.0
 REGIONAL ENTERITIS OF SMALL INTESTINE

555.2
 REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE

557.0 - 557.9
 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE - UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE

558.1
 GASTROENTERITIS AND COLITIS DUE TO RADIATION

558.2
 TOXIC GASTROENTERITIS AND COLITIS

558.9
 OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS

562.02
 DIVERTICULOSIS OF SMALL INTESTINE WITH HEMORRHAGE

562.03
 DIVERTICULITIS OF SMALL INTESTINE WITH HEMORRHAGE

569.82
 ULCERATION OF INTESTINE

569.84
 ANGIODYSPLASIA OF INTESTINE (WITHOUT HEMORRHAGE)

569.85
 ANGIODYSPLASIA OF INTESTINE WITH HEMORRHAGE

569.86
 DIEULAFOY LESION (HEMORRHAGIC) OF INTESTINE

578.1
 BLOOD IN STOOL

578.9
 HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED

579.8
 OTHER SPECIFIED INTESTINAL MALABSORPTION

579.9
 UNSPECIFIED INTESTINAL MALABSORPTION

759.6
 OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED

787.91
 DIARRHEA

792.1
 NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS

793.4
 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT




Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity 

All other ICD-9 codes not listed under "ICD-9 Codes that Support Medical Necessity" will be denied as not medically necessary. 

*


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## cpc05 (Nov 20, 2012)

Thanks!!


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## Grintwig (Nov 20, 2012)

You are welcome


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