Gastroenterology Coding Alert

Two CPT coding changes in as many years have made it difficult for gastroenterologists to know how to report the administration and analysis of Helicobacter pylori (H.pylori) breath tests. Further complicating matters is the fact that many local payers are still accepting the old CPT codes because they have not updated their reimbursement policies. By noting where the test takes place and who performs it, gastroenterologists can ensure they are paid properly for administering and analyzing the procedure.

The breath tests are a non-invasive method of detecting the presence of Helicobacter pylori, the bacteria responsible for causing gastric, peptic and duodenal ulcers, according to David A. Peura, MD, associate professor of medicine and director of clinical gastroenterology at the University of Virginia Center for the Study of Diseases Due to H.Pylori in Charlottesville, Va. Currently, there are two types of breath tests: the carbon-13 (C-13) and carbon-14 (C-14) versions. With the C-13 breath test, a baseline breath sample is taken before the liquid carbon-13 is given to the patient to swallow, Peura explains. Approximately 30 minutes later, another breath sample is taken and usually sent to a laboratory for analysis.

The C-14 breath test is given as a capsule that contains a low dosage of a radioactive isotope, Peura continues. A breath sample is taken by blowing into a balloon 10 minutes after ingesting the capsule. The sample can be sent to a laboratory for analysis, or the gastroenterologist can perform an analysis in his or her office by using a device called a liquid scintillation counter.

With both test versions, the gastroenterologist will get a positive, negative or indeterminate result back from the laboratory analysis, and no further interpretation of the test needs to be done.

New CPT Codes for C-14 Test

Although the administration of the test is fairly straightforward, The billing confusion comes from all the different codes that have been used for the tests, says Peura.

Effective Jan. 1, 2000, gastroenterologists should use code 78267 (urea breath test, C-14; acquisition for analysis) to report the administration of the C-14 breath test in their facility, says John Bacon, product manager at Ballard Medical Products, which manufactures a C-14 breath test called PyTest. The laboratory or physician that does the analysis of the C-14 breath sample should report code 78268 (urea breath test, C-14, analysis). If the gastroenterologist does the administration of the test and the analysis of the breath sample then he or she would report both codes 78627 and 78268.

For the C-13 tests, gastroenterologists should bill code 83014 (Helicobacter pylori, breath test analysis; drug administration and sample collection) to report the administration of the breath test. The laboratory performing the analysis of the breath sample should report code 83013 (Helicobacter pylori, breath test analysis [mass spectrometry]). Again, if the gastroenterologist performs both the administration and analysis of the test, then he or she should report both codes.

Local Payers May Require Outdated Codes

Even though these coding changes have been in effect for several months, the local medical review policies of several state Medicare carriers still contain outdated CPT definitions and codes. Many local Medicare payers are still using the CPT 1999 designation that codes 83013 and 83014 should be used to report both the C-13 and C-14 breath tests. Still others require the use of the now-deleted code 83019 (Helicobacter pylori, breath test) to report the analysis of the breath sample and code 99211 (office or other outpatient visit) to report the test administration.

Although Bacon says that Ballard Medical Products has sent a letter of notification about the coding changes to Medicare carriers and commercial insurance payers, he acknowledges that It takes some time to implement these changes and update all the computer systems. He also notes that the carrier makes the final determination as to which codes it will accept for reimbursement.

In addition to reporting the proper CPT code for the procedure, most Medicare carriers consider a breath test to be medically unnecessary for patients who have had an upper gastrointestinal endoscopy within the preceding six weeks or for whom an upper gastrointestinal endoscopy is planned.

Radiological Test Receives Same Reimbursement

Although the C-13 and C-14 tests are located in the CPT laboratory and radiology sections respectively, Bacon says that in the Nov. 2, 1999, Federal Register, the Health Care Financing Administration (HCFA) indicates that Medicare will crosswalk the C-14 codes to the C-13 codes and payments for both tests will be identical. Laboratory services, he explains, are reimbursed by Medicare at 100 percent of their allowable rate.

Even though the C-14 test uses a radioactive isotope, Bacon adds, a ruling printed in the Dec. 2, 1997, Federal Register from the Nuclear Regulatory Commission (NRC) states that the test is exempt from NRC licensing. In addition, neither version of the test requires any form of CLIA certification.