Gastroenterology Coding Alert

Watch out for new code 0355T for colon imaging. 

Your gastroenterologist has just recommended that a patient have a capsule endoscopy to evaluate part of his digestive system. Follow these simple guidelines to emerge a stronger coder when dealing with GI tract imaging.

Choose the Endoscopy Code According to Viewed Location

Your gastroenterologist may order a capsule endoscopy for diagnosing obscure gastrointestinal bleeding (bleeding of unknown origin) that is persistent or recurrent even after a negative initial upper GI endoscopy or colonoscopy. Diagnosis may be difficult because bleeding can often be slow and/or intermittent. Small intestinal bleeding can result from a number of conditions, including vascular lesions (angiodysplasia), small bowel tumors, celiac disease, and Crohn’s disease (which may be suspected because of other symptoms).

If the physician uses the intestinal capsule study to image the intraluminal esophagus all the way through the ileum, you should report code 91110 (Gastrointestinal tract imaging, intraluminal [eg, capsule endoscopy], esophagus through ileum, with interpretation and report).

Suppose the gastroenterologist limits her study to the patient’s esophagus only; then you should use the other capsule study code, 91111 (Gastrointestinal tract imaging, intraluminal [eg, capsule endoscopy], esophagus with interpretation and report). 

Documentation tip: “PillCam ESO® is the capsule used to perform a study limited to the esophagus. It has cameras facing in both directions in the capsule, takes more images per second, and has a shorter battery life,” informs Michael Weinstein, MD, vice president and member of the Board of Managers for Capital Digestive Care.

Your gastroenterologist might also perform a wireless capsule test for gastrointestinal pressure and transit measurement in many motility disorders of the GI tract. The reason for this method is to check gastric emptying in patients suspected to be suffering from gastroparesis or your physician may use this to investigate chronic constipation causes or other intestinal motility disorders. 

When your gastroenterologist performs a wireless capsule test for GI pressure and transit measurement, you will report the procedure and the interpretation of results using code 91112 (Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report). 

Tip: “You may see the name SmartPill® for this type of wireless capsule test,” adds Dr. Weinstein.

Sometimes, the physician may suggest the use of an Agile® patencycapsule®. The patency capsule may be administered as a precursor to PillCam® to verify adequate patency of the GI tract before the actual use of the PillCam® in patients with known or suspected strictures. You should report 91299 (Unlisted diagnostic gastroenterology procedure [Used for Patency Capsule Testing]) for this procedure. 

Effective July 1, 2014, CPT® has added a new code 0355T (Gastrointestinal tract imaging, intraluminal [eg, capsule endoscopy], colon, with interpretation and report) for intraluminal imaging of the colon, which you can report for these services. 

Beware: Payers consider codes 91299 and 0355T as representing “investigational” procedures and will not cover them. As there are many variations among payers regarding the coverage of the procedures mentioned above, you’d be safe checking your individual carrier’s policies first before submitting your claim.

Stay on the Right Side of Covered Diagnoses

Make sure that your physician has mentioned medical necessity of the procedure and codes the primary diagnosis to the highest level specified in the ICD-9. Some possible codes that you may encounter in the documentation: 

• 152.0-152.9 -- Malignant neoplasm of small intestine including duodenum
  
• 209.0-209.7 -- Neuroendocrine tumors
  
• 456.1 -- Esophageal varices without bleeding
  
• 456.21 -- Esophageal varices in diseases classified elsewhere without bleeding
  
• 571.2 -- Alcoholic cirrhosis of liver
  
• 571.5 -- Cirrhosis of liver without alcohol
  
• 571.6 -- Biliary cirrhosis
  
• 572.3 -- Portal hypertension
  
• 555.0-555.9 -- Regional enteritis
  
• 569.82 -- Ulceration of intestine
  
• 569.84 -- Angiodysplasia of intestine (without hemorrhage)
  
• 569.85 -- Angiodysplasia of intestine with hemorrhage
  
• 569.86 -- Dieulafoy lesion (hemorrhagic) of intestine
  
• 578.0 -- Hematemesis
  
• 578.1 -- Blood in stool
  

Note: Please remember that capsule endoscopy is not covered for colorectal cancer screening.

Audit-Proof Your Capsule Endoscopy Notes 

Your medical record should include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. 

Do this: Keep copies of the video images with the beneficiary’s name and the date of service included in the picture.

Additional documentation that may be required for performing capsule endoscopy is: 

• If the patient shows GI blood loss or anemia secondary to the bleeding, you must include proof that the prior upper GI endoscopy or colonoscopy did not adequately reveal the source of bleeding. 
• If the physician recorded occult gastrointestinal bleeding without iron deficiency anemia, you must attach records of the presence of occult blood in fecal samples. 
• If the provisional diagnosis is Crohn’s disease, the physician should mark down the signs, symptoms, and previous diagnostic work supporting this diagnosis and that the patient does not have an intestinal stricture. The physician also should add supporting diagnostic work if he suspects small bowel involvement.

The medical record must document the need for capsule endoscopy and contain reports or reference to the previous appropriate negative endoscopies performed prior to endoscopy by capsule.