Gastroenterology Coding Alert

You can report testing and E/M on the same day, with 25

Don't be confused by -acid reflux study- and -gastric motility study.- Although physicians commonly refer to diagnostic tests for gastroesophageal reflux disease (GERD) using these terms, your coding will improve if you think of these tests instead as -pH monitoring- and -gastric- or -esophageal manometry.-

Here are five steps to help you make the distinction.

Step 1: Link -Motility- and Manometry

If the physician refers to an esophageal -motility study,- you should choose from among three codes:

- 91010--Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study

- 91011--- with mecholyl or similar stimulant

- 91012--- with acid perfusion studies.

Of these, 91010 is the most common, with 91011 describing the basic test plus administration of a stimulant (to increase motility) and 91012 describing acid perfusion study in addition to the motility study.

The physician uses esophageal manometry to evaluate neuromuscular disorders of the esophagus. She passes a thin tube, known as a manometry catheter, through the nose into the esophagus. The manometry catheter is connected to a computer, which records the pressure waves of the esophagus during swallowing. If you see notations in the physician's notes describing these pressure readings, you know you-ve got a manometry procedure.

Step 2: Stick With 1 Code for Standard pH Test

When your gastroenterologist provides an esophageal acid reflux test using either a disposable or a reusable nasal catheter, you should report 91034 (Esophagus, gastro-esophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation), says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

In most cases, the physician will leave the catheter in place for about a day, but you will claim 91034 (without a -reduced service- or -unusual service- modifier) regardless of how long the catheter remains in place. This differs from past practice, in which you had to distinguish between standard and -extended- pH monitoring.

For example: For pH testing lasting six hours using a nasal catheter, you would report 91034. If the physician leaves the catheter in place for 26 hours, however, the coding would be the same.

Step 3: Turn to 91035 for Bravo Probe

If your gastroenterologist conducts pH testing using a Bravo capsule, you will turn to 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation) instead of 91034. The Bravo capsule has advantages over a standard catheter pH study, which can include greater patient comfort and the ability to monitor pH levels over a longer time period.

Generally, the gastroenterologist will place the capsule using an endoscope, which you may report separately in some circumstances (see -Endoscopy Can Be Separate With GERD Tests- for more information).

Step 4: Report Both Test Types, If Performed

If your GI performs manometry and pH 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, Parks says. You shouldn't need to report any modifiers to separate the services.

Another way to distinguish multiple tests: As an alternative to billing manometry and pH study on the same day, you may report the manometry on the first day and use the date of service for the pH study as the day the test is completed (in other words, you will place the probe for the pH study on the same day as the manometry, but you will report the pH study on the next day of service, after the 24-hour monitoring has concluded).

Example: The physician meets with the patient on Tuesday, performs manometry and places the probe for 24-hour pH study. For Tuesday's visit, you would report 91010, along with any significant, separately identifiable E/M service.

The patient returns on Wednesday to complete the pH study. On this date, you would report 91034 or 91035, depending on the method. In this case you would probably not report a separate E/M service because the patient returned for a planned service, not a new complaint/exacerbation that requires a revised history, exam and medical decision-making.

Step 5: Designate Separate E/M With 25

If the physician does not decide to perform the motility or pH study prior to the patient's visit, and therefore performs a significant, separate E/M service on the same date of service, you may report both the diagnostic test(s) and the E/M service. But you must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

Example: The gastroenterologist meets with a patient complaining of heartburn. He performs an expanded, problem-focused history and examination with straightforward decision-making. He orders several lab tests and discusses diagnostic and treatment options with the patient. In addition, the gastroenterologist orders the pH study and manometry to determine whether the patient is a good candidate for further surgical treatment.

In this case, you would report

- 99202-25--Office or other outpatient visit for the evaluation and management of a new patient ...

- 91034

- 91010.

Learn more: For complete information on modifier 25, see -Same-Day Service and Significant E/M Demands 25- in the January 2006 Gastroenterology Coding Alert.

Next month: Complete information on esophageal function tests 91037 and 91038.