Gastroenterology Coding Alert

For tests that last less than 24 hours, use 91032. Because the Bravo system is a 48-hour test, assign prolonged reading code 91033, Harris says. For best reimbursement results, report 91033 when the test is completed and the gastroen-terologist analyzes the results.

If the physician conducts the test in a hospital setting or ambulatory surgical center, append modifier -26 (Professional component) to indicate that the doctor does not own the equipment and is billing for the interpretation only.

If the gastroenterologist performs a manometric study (91010-91020) in conjunction with the acid reflux test (91033), report both services in addition to any E/M service provided.

For instance, suppose a primary-care provider asks a gastroenterologist to consult on a patient with heartburn. The gastroenterologist examines the patient in the office, conducts an esophageal motility study, and inserts the capsule intranasally.

Report the manometry study and the consultation, and the acid reflux test two days later. Code the esophageal motility study 91010 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study). For the outpatient consultation, report 99241-99245 (Office consultation for a new or established patient). Append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code because the procedure and the E/M service are performed on the same day.

When the acid reflux results are analyzed, assign 91033. Link the codes to any findings, such as esophageal reflux (530.81)

If the patient has more severe symptoms, such as difficulty swallowing, the gastroenterologist may perform an endoscopy in a hospital or ambulatory surgical center and place the Bravo capsule during the procedure. For the diagnostic endoscopy, assign 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) or 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]).

When the pH study is complete, report 91033-26.

"I've had little success being reimbursed for the prolonged acid reflux test, says Martha Martinez, office manager of South Bay Endoscopy Center in San Diego. When she submits claims for 91033 with 43235, most payers reimburse for the endoscopy only.

"Our doctors like the Bravo system and are using it now, but I don't know how cost-effective it will be," she notes. "Maybe when the insurers have dealt with it more, reimbursement will improve."

If an endoscopy is performed to evaluate symptoms and, at that time, the device is attached because of the findings, it should be possible to obtain reimbursement for both procedures, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.

"The multiple-procedure modifier -51 might apply," Weinstein says. "Performing both of these procedures on the same day will be a change in the usual management of patients with GERD. Also keep in mind that an appeal may be needed if the second procedure is denied, and providers should expect a 50 percent reduction in the fee for 91033."

Third-party payers will probably not reimburse for endoscopies that are performed only to place the Bravo pH-monitoring capsule, says Joel Richter, MD, chairman of the department of gastroenterology and hepatology at Cleveland Clinic in Ohio. The capsule must be placed in a precise location, at the juncture of the stomach and esophagus. If the gastroenterologist has performed an endoscopy on the patient, the doctor will probably know this landmark.

"I wouldn't want to see special endoscopies done just for this," Richter says. "I would urge physicians to note the location of the juncture during other endoscopies on the patient. Patients with chronic acid reflux have to have at least one endoscopy so you can see what's going on in the esophagus. Of course if you don't have the landmark information already, then you have to do the endoscopy before you can place the capsule."

The Bravo device costs considerably more than standard nasal probes, Weinstein says. When the system is used in the office setting, bill unlisted supply code 99070 (Supplies and materials, provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) or A4649 (Surgical supply; miscellaneous). Submit all relevant documentation with the initial claim.