Gastroenterology Coding Alert

Knowing what anatomy the capsule study evaluates is the key to choosing between 91110 and 91111. Follow these expert-approved steps to picking the perfect code -- and modifier -- for all of your pill cam claims.

When your gastroenterologist uses a capsule study to image the intraluminal esophagus through the ileum, you'll report 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report).

Take into account placement: If your gastroenterologist places the pill cam for the capsule study, you should report 91110 with modifier 52 (Reduced services). "The descriptor of 91110 clearly states the evaluation is from the esophagus to the ileum. The endoscopic placement of the capsule makes it technically impossible for the physician to perform the assessment of the esophagus (and potentially the stomach, depending on where the physician deploys the capsule)," says Joel V. Brill, MD, AGAF, chief medical officer at Predictive Health LLC in Phoenix.

Important: Your practice must maintain appropriate clinical and billing records in case a payer elects to audit claims, Brill adds.

You've got another capsule study code at your disposal. You should use this one when your gastroenterologist's study is limited to the esophagus only.

In a nutshell: Code 91111 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus with physician interpretation and report) represents visualizing the esophagus only, whereas 91110 indicates visualizing the esophagus, stomach, duodenum, jejunum and ileum. This means when you report 91111, you're describing a less inclusive study than 91110.

Catch this: Because 91110 automatically includes 91111, CPT added text directing coders not to report 91111 in addition to 91110. So you should not report these codes together.

Rationale: "CPT created 91111 to report the PillCam ESO. The PillCam ESO is different from the PillCam SB (small bowel), as it is designed to specifically visualize the esophagus," Brill says. The wireless capsule has cameras at both ends with a short battery life.
Providers can test for esophageal reflux and varices, experts say. The patient is not required to take a full day off work because he will not undergo sedation and can be at the practice for the entire test, which only takes 20 minutes.-

Caution: You may still have a struggle for reimbursement. Some payers consider PillCam ESO "investigational" and will not cover the procedure.

Tactic: Look up the FDA approval dates that make the procedure no longer investigational and provide the date and approval number, experts say.

Don't forget: Also, be sure you've got your modifiers in order. If the physician provides only the professional portion of the procedure (that is, interpretation and report of the results), you should append modifier 26 (Professional component) to 91111. If your physician provides both the professional and technical components of the procedure, you needn't attach any modifiers.

Again, you should always make sure you maintain appropriate clinical records in case the payer elects to audit claims, Brill says.

Some practices are reporting situations in which the capsule is stuck in the stomach and requires the physician to advance the capsule into the intestine using an endoscope.

Problem: If you try to bill for the endoscope, "you will have a problem for medical necessity because you won't have any real reason for doing this service -- except for pushing the capsule through," says Mary Vollmer, coder at Allied GI Associates in Haddon Heights, N.J. "I don't think that would fly with insurance companies."

In these situations, you can add modifier 52 to reflect that the capsule imaged the patient's anatomy until it became lodged in the stomach or modifier 53 (Discontinued procedure) to represent the start but eventual stop of the procedure.