Gastroenterology Coding Alert

Discover what documentation you need to ensure proper payment

When your gastroenterologist performs a Bravo capsule pH test at the same time as a reflux test, you know already that you-re going to report multiple codes, but knowing to include an EGD code is key. Get the inside scoop on how to tackle these claims by breaking down the following example.

Example: A patient with a history of reflux esophagitis reports to your office. The gastroenterologist performs an esophagogastroduodenoscopy (EGD) and takes a biopsy, administers the reflux test and inserts a Bravo capsule.

Break Down the Problem

Step 1: When your gastroenterologist inserts a Bravo capsule, he must first perform an EGD to determine how far down to place the capsule, says Merrilee Severino, CPC, practice manager for Advanced Gastro and Liver Care PA in Pinellas Park, Fla. Sometimes, the EGD is diagnostic, and other times, the gastro takes a biopsy, she says.

In other words, you should report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) for the EGD.
 
Turn to 91035 for Bravo Procedure

Step 2: If the gastroesophageal reflux test includes a Bravo capsule insertion during the same session, you should use 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation) for the Bravo portion, says Olga Cabrera, CMM, CPC, CGCS, office manager at Citrus Gastroenterology PA in Inverness, Fla. You-ll report this code in addition to 43239. Keep in mind: Payers include the cost of the capsule in 91035.

When would the doctor do this? Your gastroenterologist might choose to perform a Bravo insertion and a reflux test during the same session for many reasons. For instance, some physicians insert the Bravo capsule over a standard pH probe because the capsule is catheter-free. Patients can go about their normal days. Also, the gastroenterologist can get 48 hours of information as opposed to only 24 hours, as would be the case with the standard pH probe.

Don't forget: You should attach 530.11 (Reflux esophagitis) to both 43239 and 91035 to prove medical necessity for the procedures.
 
Service-date alert: When you report 91035, the date of service should be the date your gastro retrieves the  data-collection recorder. -We-ve always understood it to be this way -quot; unless you-re billing the interpretation separately,- Severino says.

Exception: In the above example, if the gastro did not take a biopsy, you would report 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the EGD instead of 43239.

Paperwork Must Back Up 91035 Claim

Step 3: For 91035 claims, most payers are serious about their documentation requirements. Check out the documentation requirements for reporting 91035 from Highmark, the Medicare carrier for Pennsylvania. You should keep these tips in mind when reporting 91035:

- -Documentation supporting the medical necessity of the procedure, including the requirements listed under the -Indications and Limitations of Coverage- section of this policy, must be maintained in the medical record.-

- -Documentation must be maintained in the medical record to support that the patient presents diagnostic problems associated with atypical symptoms or the patient's symptoms are suggestive of reflux, but conventional tests have not confirmed the presence of reflux.-

- -Documentation must be available to Medicare upon request (e.g., physician interpretation and report).-