Gastroenterology Coding Alert

Tip: Heeding local payer criteria for testing is crucial for getting paid.

If you gastro reports H. pylori tests, you’ll need to ensure that you know when you are eligible to claim the tests, how to report various aspects of the tests, and what pitfalls await you if you slip. Find out if you’re getting the maximum mileage out of the tests your practice administers. 

Choose Your C’s For Breath Tests 

The breath tests are a non-invasive method of detecting the presence of H. pylori, the bacteria responsible for causing gastric, peptic, and duodenal ulcers. 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 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 can be analyzed at your office or 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. 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 in your facility you have 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 both 78627 and 78268 for the C-14 test, or 83013 and 83014 for the C-13 variety.

Go to Other Confirmatory Tests for Special Cases

As the urea breath test is cleared by the FDA only for use in adults (18 years of age and older), another test called stool antigen testing is the preferred method of testing for H. pylori infection in pediatric patients, which has been cleared by the FDA for use in both adults and children.The stool antigen test (such as Meridian bioscience HpSA) is based on the passage of H. pylori bacteria and H. pylori antigens in the gastrointestinal tract, and their detection by immunoassay. For reporting the stool test, you should report code 87338 (Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool).

“Another method for confirming the H. pylori infection is through endoscopy with biopsy,” informs Michael Weinstein, MD, Vice President of Capital Digestive Care. American Gastroenterological Association (AGA) suggests that 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, or family history of upper gastrointestinal cancer) should be evaluated by endoscopy with biopsy. “If your gastroenterologist performs this procedure, you can report it with a suitable and applicable code 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple),” adds Weinstein.

Support the Tests With Correct Diagnosis Codes

You may have correctly reported the administration and analysis of the H. Pylori, but you still have to ensure that you have attached the right diagnosis codes to your claim. Some of the accepted ICD-9 codes that you should look for in your physician’s notes are 

• 008.43 (Intestinal infection due to Campylobacter), 
  
• 041.86 (Other specified bacterial infection, Helicobacter pylori [H. pylori]), 
  
• 531.00-531.91 (Gastric ulcer), 
  
• 532.00-532.91 (Duodenal ulcer), etc.
  
• 536.8 (Dyspepsia and other specified disorders of function of stomach)
  

Caution: However, you should note the codes that are not accepted, such as 280.0 - 285.9 (Anemia), 560.0 - 560.9 (Intestinal obstruction without mention of hernia), 569.83 (Perforation of intestine), 783.21(Loss of weight), among others. Make sure to check with your local payer to understand the acceptable codes in your area. 

Ensure Medical Necessity before Administering H. pylori Tests

“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,” cautions Weinstein.

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;

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. 

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), or screening of asymptomatic persons for H. pylori infection.