Gastroenterology Coding Alert

Check for clues in the documentation for improved accuracy.

When your physician treats gastroesophageal reflux disease (GERD), he may conduct diagnostic tests such as esophageal motility studies to evaluate the condition prior to a surgical intervention. See our advice below appropriately coding these tests for optimal results.

Look for Both Manometry and pH Monitoring

If your gastroenterologist is trying to evaluate the patient's esophagus for neuromuscular disorders, he is more likely to opt for esophageal manometry. "Esophageal manometry studies are used to evaluate how well the esophagus functions," says Bridgette Martin, LPN, CPC, CGIC, Coding Specialist-Gastroenterology Associates, Evansville, Indiana. "They may also be ordered to evaluate a patient prior to recommending anti-reflux surgery." The patient's documentation will probably show mention of a "manometry nasal catheter" and pressure readings. You report this procedure with 91010 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report).

Sometimes, your gastroenterologist might opt for the use of a medication stimulant during the motility studies. In such a scenario, you report the procedure with 91013 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; with stimulation or perfusion [e.g., stimulant, acid or alkali perfusion] [List separately in addition to code for primary procedure]).

Another test that your gastroenterologist will usually perform while assessing a patient with GERD is pH monitoring using a pH probe placed through a nasal catheter. "pH studies help determine whether or not a patient has GERD," says Martin. "CPT code 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation) is reported for nasal catheter pH study."

Example: Your gastroenterologist sees a patient suffering from recurrent heartburn that has not subsided with lifestyle changes and acid suppression medications prescribed six weeks prior. Your gastroenterologist advises the patient to stop medications for one week and orders a pH monitoring test. A pH monitoring probe is inserted using an intranasal catheter and the cassette attached to the other end of the probe is activated to capture the data. Your gastroenterologist asks the patient to return after 24 hours. Upon return, your gastroenterologist retrieves the data in the cassette for interpretations. You report the procedure with 91034.

Separate Technical and Professional Components When Necessary

If your gastroenterologist practices in a hospital setting and does not own the equipment for the motility tests, you might have to separate the technical and professional components. "If the physician does not own the equipment, you would bill the CPT 91010 with a modifier 26 (Professional component) to claim the professional component of the service," says Linh Nguyen, CPC, Medical Coder-Gastroenterology Associates, Evansville, Indiana. "The TC modifier is used for the entity claiming reimbursement for the use of the equipment."

However, if your gastroenterologist owns the equipment, then you have to just stick to the appropriate test codes and bill globally without the use of any modifiers. "The value of the code includes payment for both the professional and technical components," says Nguyen. The billing date for the pH monitoring test should be the date on which the data capture cassette is retrieved from the patient.

Don't Always Bill for Endoscopies

Your gastroenterologist might also perform an endoscopy to evaluate the person for GERD. If the procedure has been performed for evaluation, you can report the procedure with the appropriate code for the endoscopy (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]).

Your gastroenterologist might prefer the use of a Bravo capsule for pH monitoring. You report the procedure with 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation). To insert the Bravo capsule, it is necessary to know the distance from the teeth to the lower esophageal sphincter. Your gastroenterologist might need to perform endoscopy on the day of the Bravo insertion if the distance is not known from a prior endoscopy. "If the sole purpose of the endoscopy is to place the Bravo capsule, then the endoscopy should not be reported separately," says Martin.

"However, if it is medically necessary to perform an EGD to evaluate the symptoms in addition to determining the location for placement of the capsule, then both procedures (EGD and Bravo capsule) can be billed," says Martin. In this scenario, you would bill the EGD on the date of service of the endoscopy, with the appropriate symptom code (530.81, Esophageal reflux). Then, bill 91035 for the day the doctor interpreted the test, which should be 48 hours later."

Observe These Guidelines for Billing Tests and E/M on Same Calendar Date

If your gastroenterologist is performing manometry and pH studies on the same patient on the same date of service (DOS), you can report both the procedures with no modifiers attached as there are no CCI (Correct Coding Initiative) edits for these procedures. Alternatively, "we will see 91010 with the DOS of the study, and the 91034 with a DOS of the interpretation " for instance, the following day," adds Martin.

When the physician performs a significant and separate E/M service on the same calendar date as the motility studies, you can report the E/M service separately using the 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 E/M code.

Example: Your gastroenterologist sees a patient in his office to assess heartburn that is not subsiding with previously prescribed medications. Your gastroenterologist performs a thorough evaluation of the patient (duration of 20 minutes) prior to ordering diagnostic manometry and pH studies to assess if the patient needs to be considered for surgical treatment.

You report the E/M with 99214 (Office or other outpatient visit for the evaluation and management of an established patient...) with modifier 25. You will report 91010 for the manometry studies and 91034 for the pH monitoring (date of service can be the day of interpretation).