Gastroenterology Coding Alert

Test your knowledge of coding for breath tests and other investigative services.

Your gastroenterology practice is probably reporting H. pylori tests - but are you doing so correctly? Errors abound for these services, and many offices don't even realize they're making mistakes. Take the following quick quiz and then evaluate how you fared to determine whether you're a coding ace or you could use some pointers.

Differentiate C-14 From C-15

Question 1: Your gastroenterologist has always performed the C-13 breath test, but this week he started performing the C-14 test. Which code should you report for these?

Answer 1: As the question suggests, there are two typesof 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 from the patient and then liquid C-13 is given to the patient to swallow. Approximately 30 minutes later, another breath sample is taken and canbe analyzed at your office or sent to a laboratory foranalysis.

The C-14 breath test is given as a capsule that contains a low dosage of a radioactive isotope. The patient gives a breath sample 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.

Challenge: It is sometimes difficult to know how to report the breath tests, or urea tests as they are also known, because coding for these tests has two aspects - the administration and analysis. By noting where the test takes place and who performs it, you can ensure you are paid properly for administering and analyzing the procedure.

Admin: To report the administration of C-13 test, you should bill code 83014 (Helicobacter pylori; drug administration) to report the administration of the test. To report the administration of the C-14 breath test, report 78267 (Urea breath test, C-14[isotopic]; acquisition for analysis).

Analysis: The laboratory or physician that does the analysis of the C-14 breath sample should report code 78268 (Urea breath test, C-14 [isotopic]; analysis). The facility performing the analysis of the C-13 sample should report code 83013 (Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope [e.g., C-13]).

If the gastroenterologist performs both the administration and analysis of the tests, then he or she would report both codes depending on which test is performed. You would report both 78267 and 78268 for the C-14 test, or 83013 and 83014 for the C-13 variety.

What If the Test Is Performed Via Endoscopy?

Question 2: You see a patient with suspected H. pylori infection and the gastroenterologist performs endoscopy with biopsy to confirm the presence of the bacteria. Which code covers this?

Answer 2: Gastroenterologists often prefer this method with patients older than 55 years of age and younger patients with alarm symptoms (e.g., weight loss, progressive dysphagia, recurrent vomiting, evidence of gastrointestinal bleeding, patients taking antibiotics or strong acid blocker medications, or family history of upper gastrointestinal cancer). If your gastroenterologist performs this procedure, you can report it with a suitable and applicable code, such as 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple).

Know Which Dx Code(s) to Report

Question 3: You are clear on reporting the H. pylori procedure codes, but how should you report the diagnosis for these services?

Answer 3: You'll report the code for the definitive condition, if found, or the symptoms that prompted the test if you don't have the results back yet (or if the results are negative). Some of the generally accepted ICD-10 codes that you may find in your physician's notes include the following, among others:

• B96.81 - Helicobacter pylori (H. pylori) as the cause of diseases classified elsewhere
• C16.0-C16.9 - Malignant neoplasm stomach...
• K25.0-K25.9 - Gastric Ulcer...
• K26.0-K26.9 - Duodenal Ulcer...
• K27.0-K27.9 - Peptic Ulcer...
• K28.0-K28.9 - Gastrojejunal Ulcer...
• K29.00- K29.91 - Gastroduodenitis...
• K30 - Functional dyspepsia
• Z87.11 - Personal history of peptic ulcer disease

Remember to check with your payer on which codes are payable by each individual contractor.

Ensure Medical Necessity before Administering H. pylori Tests

Question 4: You performed an upper GI endoscopy three weeks ago on a patient, and last week, you performed an H. pylori breath test, which the payer promptly denies. What caused the denial?

Answer 4: Before coding for a breath test, you have to ensure that patient has not had an upper gastrointestinal endoscopy within the preceding six weeks and does not have an upper gastrointestinal endoscopy planned. This is because most Medicare carriers may not pay for the test as they consider a breath test to be medically unnecessary for such patients.

Also make sure that you have complied with your local payer's conditions of medical necessity for the H. Pylori tests. For example, Aetna considers carbon isotope (C-13 or C-14) urea breath testing or stool antigen testing medically necessary only for patients who meet one of the following criteria:

1. Evaluation of new onset dyspepsia in those younger than 55 years of age with no alarm symptoms
2. Evaluation of persons with persistent symptoms of dyspepsia despite two weeks of appropriate antibiotic therapy for Helicobacter pylori (H. pylori);  
3. Recurrent dyspeptic symptoms suggesting re-infection with H. pylori;
4. Re-evaluation to assess success of eradication of H. pylori infection.
5. Before starting proton pump inhibitor therapy for dyspepsia
6. Before bariatric surgery for obesity

Moreover, Aetna does not pay for urea breath testing and stool antigen testing if done for all other indications, including risk of developing dementia, dyspepsia associated with "alarm" markers, e.g., anemia, gastrointestinal bleeding, obstruction, perforation, anorexia, early satiety, or weight loss (upper gastrointestinal [GI] endoscopy is indicated), evaluating infantile colic, managing recurrent aphthous stomatitis, new-onset dyspepsia in those aged 55 years or older, or screening of asymptomatic persons for H. pylori infection.

Keep in mind: Check with your payer for its specific guidelines for these tests, as the Aetna policy is just one example.