Gastroenterology Coding Alert

Reporting multiple tests in one day will not get you in trouble.

According to estimates, up to 60 percent of the population experience symptoms of gastroesophageal reflux disease (GERD) or acid reflux, such as heartburn and acid regurgitation, at some time during the year. GERD occurs when the lower esophageal sphincter (the valve separating the esophagus and stomach) does not close properly, allowing acid and stomach contents up into the esophagus.

Usually, attending GIs can recognize GERD from common symptoms but complicated cases may need additional tests to be definitively diagnosed. We guide you through the process of GERD diagnosis coding by removing the jargon surrounding the tests so that you don’t have to search for codes when you encounter such cases.

Here are five steps to help you make the distinction.

Step 1: First and Foremost, Take Medical History

When GERD patients present in your physician’s office with heartburn, chest pain or similar symptoms, the GI will first attempt to take the patient’s history and detailed symptoms. He will perform a problem-focused history and examination with straightforward decision making. Many times, the physician may be sufficiently satisfied with the symptoms for a confirmed diagnosis and start the patient on GERD medication to relieve the symptoms. Don’t miss this coding opportunity by watching out for the most common symptoms such as:

• 787.1 (Heartburn)
• 786.2 (Cough)
• 530.1x (Esophagitis)
• 536.8 (Dyspepsia and other specified disorders of function of stomach)
• 786.07 (Wheezing)
• 476.0 (Chronic laryngitis)
• 476.1 (Chronic laryngotracheitis)
• 464.xx (Acute laryngitis and tracheitis).

Link these codes to appropriate E/M codes 99202-99205 for reporting the encounter. The code for confirmed GERD is 530.81 (Esophageal reflux).

Moreover do note any pre-existing chronic conditions and habits that may exacerbate GERD such as asthma (493), obesity (278), smoking, pregnancy and hereditary predilection.

Step 2: Check Out this EGD Code Range

If the patient’s GERD symptoms are not relieved after lifestyle changes and medications, the gastroenterologist may use an upper endoscopy, also known as an esophagogastroduodenoscopy (EGD). The GI uses an endoscope—a small, flexible tube with a light—to observe the upper GI tract and can perform this test at a hospital or an outpatient center. The person may receive a liquid anesthetic that is gargled or sprayed on the back of the throat. If sedation is used, a health care provider will place an intravenous (IV) needle in the person’s vein. You can choose from within the code range (43235-43259, esophagogastroduodenoscopy) to report the procedure.

Step 3: Differentiate Between Standard pH and Bravo Test

If the physician is not sure of the symptoms, he may order one or more of several tests for accurately diagnosing the condition. 

Standard pH: One of them is the esophageal acid testing. Also known as an esophageal pH test, the acid reflux test is considered a “gold standard” for diagnosing GERD, in which the amount of time that the esophagus contains acid is determined through pH testing.

Irrespective of whether your gastroenterologist conducts an esophageal acid reflux test using either a disposable or a reusable nasal catheter, you should report 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation) for a standard pH test. You can bill for the same code without modifier even in cases of a “reduced service” or “unusual service” encounter regardless of how long the catheter remains in place. According to Michael Weinstein, MD, vice president and member of the Board of Managers for Capital Digestive Care, “The code includes both a technical component for the device and recording equipment, and a professional reading component. If your GI only performs the reading then you should attach modifier 26 (Professional component) to the service while the owner of the device will attach modifier TC (Technical component). If your practice owns the device then you will bill for both components by listing the CPT® code without a modifier.”

Bravo Test: Another method for prolonged measurement (48 hours) of acid exposure in the esophagus is the Bravo test where a small, wireless capsule is attached to the esophagus just above the LES. The capsule measures the acid refluxing into the esophagus and sends the information to a receiver. The study, usually lasting 48 hours, analyzes the information from the receiver after recording it in a computer. 

For the Bravo test, you should code 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation) instead of 91034. Generally, the gastroenterologist will place the capsule after performing an endoscopy to investigate symptoms and to identify the proper location for the Bravo, which you may report separately in some circumstances.

Step 4: Don’t Fret Over Motility and Manometry

Using pH testing methods are not perfect for diagnosing GERD in abnormal cases. In such cases, gastroenterologists refer to another test known as an esophageal “motility study.” Don’t get confused as the same test is also popularly referred to “esophageal manometry.” This test determines how well the muscles of the esophagus are working. The physician passes a thin tube (catheter) through a nostril down into the esophagus with one end equipped with a sensor that sends esophageal movement information back to a recorder, which records the pressure waves of the esophagus during swallowing. Tip: If you see physician’s notes describing these pressure readings, you know you’ve got a manometry procedure.

The GI may sometimes administer a stimulating agent to aid in motility testing. He may also order acid perfusion studies along with manometry. For the basic test you should use 91010 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report) and +91013 (... with  stimulation or perfusion …) if a stimulant was given or perfusion was performed. The acid perfusion (Bernstein) test is used to confirm whether the symptom of chest pain has been really caused due to GERD. 

Step 5: Go to Barium Swallow Tests for Accurate Visualization

One of the other prominent investigative tests for GERD is the upper gastrointestinal (GI) series. Also known as a barium swallow test, this is a radiological test that is used to visualize the structures of the upper digestive system — the esophagus, stomach and duodenum. Sometimes, a small bowel series can be added to the test to see the remaining parts of the small intestine. You should check with your gastroenterologist about what to do to prepare for an upper GI series.

For a Barium swallow test, you can code 74220 (Radiologic examination; esophagus) and the radiologist will report the GI series with radiology codes from within 74240-74249 and submit them to the GI.

Step 6: Report Multiple Tests with Confidence

If your GI performs EGD and Bravo study for the same patient, you may report the procedures separately and expect separate reimbursement, even if the tests occur on the same date of service. You should be able to report the services without any modifier. 

Another work around is to bill one test on the day of the procedure and the other on the day another procedure is completed even if it was initiated with the first test — for example, in a manometry and pH study, you may report the manometry on the first day; then, you should use the date of service for the pH study as the day the test is completed after the 24-hour monitoring.

Example: A patient with a history of GERD presents in your office. The GI conducts an esophagogastroduodenoscopy (EGD) and takes a biopsy, determines the location of the lower esophageal sphincter and inserts a Bravo capsule using the delivery catheter above the sphincter. Your primary code for the EGD should be 43239 ( Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple). Then, you will report 91035 for the Bravo capsule insertion during the same session but bill with the date of service that the GI collected the recorded data. Usually, that is two days later. Don’t forget to link the procedures to 530.81 to prove medical necessity.