Gastroenterology Coding Alert

Discover what 3 modifiers you'll use coding capsule studies.

When a patient presents to your office for a capsule study and the capsule gets lodged in hisstomach, would you know how to bill your claim?

A good sense of what anatomy the capsule study evaluates could save you from a possible coding disaster. It's not enough that you know the two CPTs to use for this study: 91110 and 91111. Find out the answers to coders' frequently asked questions (FAQs) and you wouldn't have to worry about picking the right code.

1. How Would You Report a Repeat Procedure with 91110?

Sometimes, your gastroenterologist would use a capsule study to image the intraluminal esophagus all the way through the ileum and reaching the colon. In this case, you should report 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report).

Example: Patient comes in for a capsule endoscopy, but the capsule gets stuck in foodon hour five and visuals cannot be seen past the stomach. The gastroenterologist ends up repeating the procedure to see if she can see the small and large intestine.

Code it: First, you would code 91110 and then attach modifier 53 (Discontinued procedure) to indicate that the physician repeated the procedure. If the physician decides not to repeat the procedure, you should append modifier 52 (Reduced services) to reflect that the capsule imaged the patient's anatomy until it became lodged in the food.

Tip: If you plan on repeating 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 91110's descriptor clearly states the evaluation is from the esophagus to the ileum. The only time this won't be true is when the gastroenterologist places the pill cam endoscopically for the study, says Joel V. Brill, MD, AGAF, chief medical officer at Predictive Health LLC in Phoenix. Again in this case, you should attach modifier 52 to 91110.

2. What Does 'SB' and 'ESO' Mean on PillCam Labels?

Suppose the gastroenterologist limits her study to the patient's esophagus only -- without going further down the stomach, duodenum, jejunum and ileum. In this case, you should go for the other capsule study code: 91111 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus with physician interpretation and report).

Take note that the physician would use two different types of wireless capsuleswhen performing 91110 and 91111, respectively. PillCam SB (small bowel) is designed specifically to visualize the esophagus, stomach, duodenum, jejunum, and ileum. It has one camera and a battery that can last up to eight hours. On the other hand, PillCam ESO covers the esophagus. It has cameras at both ends of the capsules and takes very rapid images but the battery lasts only a short time.

Careful: Don't dare report 91110 and 91111 together because the work required in 91111 is already included in 91110, according to Correct Coding Initiative (CCI) edits. Since some payers consider PillCam ESO "investigational" and will not cover the procedure, you'd be safe checking your payer's policies first before submitting your claim.

3. Where Professional/Technical Components Matter

In many regions, hospital endoscopy suites purchase the capsules , and hospitals own the equipment used to view the capsule video. If the physician provides only the professional portion of the procedure (i.e., interpretation and report of the results), you should append modifier 26 (Professional component) to the CPT. Don't worry about attaching any modifiers if the physician purchases the capsule and owns the computer video equipment. In that case the physician provides both the professional and technical components of the procedure.

Piece of advice: Make sure you maintain appropriate clinical and billing records in case the payer elects to audit claims.