Gastroenterology Coding Alert

Reporting capsule endoscopy is not just about knowing the procedure codes and when to use them. It is also about being proficient enough to report interrupted procedures, delayed procedures, or other such contingencies. Remain on top of these situations armed with the knowledge of the correct modifiers. 

 

If you are reporting only the professional component for your capsule endoscopy services ((i.e., interpretation and report of the results), you should append professional component modifier 26 (Professional component) to the appropriate code. For example, if your physician is part of a facility, and the facility owns the equipment used for the endoscopy, the gastroenterologist will only report the professional component.

 

When you are reporting only the technical component for the service, append technical component modifier TC to the code unless the hospital provided the technical component. In that case, do not append modifier TC because the hospital’s portion is inherently technical. Also, don’t append a professional or technical modifier to the code when reporting a global service in which one provider renders both the professional and technical components.

 

When your physician needs to repeat or discontinue the procedure, you’ll need to ensure you understand how to apply modifiers 52 and 53. 

For instance, if the capsule gets stuck in food during a capsule endoscopy procedure and the gastroenterologist cannot visualize past the stomach, then she has to repeat the procedure to see if she can see the small and large intestine. In such a case, you have a modifier 53 (Discontinued procedure). “First, you would code 91110 and then attach modifier 53 to indicate that the physician intends to repeat the procedure. 

 

If the physician decides not to repeat the procedure, you could append modifier 52 (Reduced services) to reflect that the capsule imaged the patient’s anatomy until it became lodged in the food. Each carrier may have a different policy as to how it reimburses for these modifiers,” explains Michael Weinstein, MD, vice president and member of the Board of Managers for Capital Digestive Care.

 

Tip: If you plan to repeat a capsule study due to technical problems, it is a good idea to pre-authorize payment for the second study with the carrier. You may need to provide records of the incomplete study.

CPT® code 91110’s descriptor clearly states the evaluation is from the esophagus to the ileum. However, you may encounter exceptions. This is true when the gastroenterologist has to place the PillCam® endoscopically for the study. You may think that you can attach a modifier for reporting this exception. However, you would be wrong. “You can’t employ a modifier here because even when a scope is used to push the capsule into the duodenum, it has already imaged the esophagus when the patient swallowed the capsule,” says Dr. Weinstein. 

 

Medicare modifier: For Medicare beneficiaries undergoing capsule endoscopy of the esophagus, the record must show that the patient does not have a contraindication for nonselective beta-blocker use. In such cases, you must append a KX modifier (Requirements specified in the medical policy have been met) to CPT® code 91111. Examples of likely contraindications would be bronchial asthma, sinus bradycardia and greater than first-degree heart block and overt congestive heart failure.