Gastroenterology Coding Alert

Getting reimbursed for esophageal manometry and acid reflux studies performed on the same date of service has become more difficult, according to many Gastroen-terology Coding Alert readers. Many coders who frequently bill these tests advise that the way around this coding dilemma is to report the tests as of the date they were completed instead of when they were initiated.

Esophageal manometry (91010) is used to evaluate neuromuscular disorders of the esophagus. A small catheter with water flowing through it is placed in the patient's esophagus and inserted into the stomach. The catheter is then withdrawn at half-inch intervals while a pressure profile of the lower esophageal sphincter is taken at each point.

During an acid reflux test (91032 and 91033), which is also referred to as pH monitoring, a catheter probe is passed through the patient's nose and down to the distal esophagus. Attached to the other end of the probe is a cassette worn on the belt that records the extent of the acid reflux. After the cassette is activated, the patient is sent home and is usually asked to return in 24 hours, and the probe is removed.

Both tests are usually administered by a nurse or technician, regardless of whether the setting is a hospital, ambulatory service center or office. The test results are compiled and presented to the gastroenterologist, who then reads or interprets the results.

It is not unusual to first administer the esophageal manometry test and then insert the probe for the acid reflux test during the same session. Some gastroenterology practices bill both tests on the same date of service and have no problems getting reimbursed.

"We report multiple tests on the same day and don't do anything to distinguish that they are separate like using modifier -51 [Multiple procedures] or -59 [Distinct procedural service]," says Kimberly B. Green, CPC, project coordinator at the University of Pittsburgh Physicians where she works with 25 gastroenterologists. "I've seen questions about what date of service should be used and wondered if we were doing this right, but I've never seen anything in writing from Medicare or CPT about what to do."

Other practices use the date that the gastroenterologist interprets the test results as the date of service, which sidesteps the issue of billing for multiple procedures on the same day. "Our date of service is the day that the test is completed," says Jill Barron, CPC, coding manager at Gastroenterology Associates of Cleveland Inc. "The gastroen-terologist gets called over to the hospital to read the test results either the day the test is administered or the day after, if it's a 24-hour pH study, so when we will bill both it ends up being for different days."

Another advantage to billing on the date that the test is read is that this ensures the test was completed. "We don't bill until the gastroenterologist reads the results in case something happens and the test isn't completed," says Stephanie Goodfellow, billing manager at the Mid-America Gastro-Intestinal Consultants in Kansas City, Mo. "We've had acid reflux tests that looked good, but the scan shows that nothing's there. The monitor malfunctioned, and we can't bill for that test."

Although she bills as of the date the test was administered, Green also believes that it is important to make sure the 24-hour monitoring has been completed before reporting it. "We wait until the patient comes back to the hospital before billing for the acid reflux test, but we use the day the probe was inserted as the date of service," she says. "I wait on the billing to make sure the test gets read. We do have patients who don't finish the 24-hour monitoring."

Another coding suggestion for esophageal motility studies is to use the "type of service" or TOS indicator of 9 (Other medical services) on the claim. Barron has noticed that some coders are using a TOS indicator of 2, which is for surgical procedures, and believes this may cause the claim to be denied because it probably doesn't match the payer's designation for the service.

Other coding tips for motility studies include the following:

1. Use 91033 for 24-hour pH monitoring. Although 24-hour testing is the norm for acid reflux tests, and the CPT definition for 91033 indicates that it is for prolonged recordings, our coding experts agree that this is the code for 24-hour testing. None of them had ever reported 91032 for a test that took less than 24 hours.

2. Discontinued tests don't get billed. Although manometry or acid reflux tests are sometimes discontinued because the patient can't tolerate the catheter or the probe, our sources don't bill for tests that are not completed. Because her practice owns the equipment used to perform the acid reflux test, Goodfellow bills supply code 99070 (Supplies and materials [except spectacles], 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]) to cover the cost of any disposable tubes used during a discontinued procedure. She also attaches documentation to the claim to indicate that the test was discontinued.

3. Attach modifier -26 if the gastroenterologist reads the results only. The manometry and acid reflux tests include a technical and professional component. The technical component represents the value assigned to the ownership and maintenance of the equipment and is indicated by modifier -TC (Technical component). The professional component represents the gastroenterologist's interpretation of the test results and is indicated by modifier -26 (Professional component).

Because the majority of these tests are performed in a hospital setting due to the high cost of the equipment, most gastroenterologists bill for the professional component of the test only. In these situations, the hospital will bill for the technical component of the test; providers never bill for only the technical component.

Even though Green's gastroenterologists are employed by the hospital, she still adds modifier -26 to their claims because the hospital owns the equipment. "This isn't a private practice," she explains. "The gastroenterologists don't own the equipment."

When the gastroenterology practice owns the equipment, the global code should be billed with no modifiers, and the reimbursement will include the technical and professional components. Because Goodfellow's practice owns the equipment for the acid reflux tests, she bills the global code 91033. However, the practice does not own the manometry equipment, and the patients are sent to the hospital. Goodfellow can only bill for the professional component for the manometry test and attaches modifier -26 to the code.