Gastroenterology Coding Alert

Patients needing 24-hour pH monitoring of esophageal acid reflux used to be referred to esophageal motility specialists at university medical centers. Because more gastroenterologists have started performing this test themselves, however, they have to deal with the complexities of billing for a procedure that is unlike the more familiar endoscopies and contains both a technical and professional component.

Back in the old days, the university medical centers used to be the only ones doing esophageal motility studies, says Kenneth Koch, MD, who specializes in esophageal motility studies at the Milton S. Hershey Medical Center and Penn State University College of Medicine in Hershey, Pa. These days, however, as gastroenterology practices get bigger and start to approach five to eight gastroenterologists, one physician will often start to develop a specialty in that area.

Contains a Technical and Professional Component

With 24-hour pH monitoring of esophageal acid reflux, a probe is inserted, often by a nurse, into the patients nose and is passed through to the esophagus. The probe is attached to a cassette that records the extent of the acid reflux in the patient for the next 24 hours. After the cassette has been activated, the patient goes home and is asked to record symptoms of acid reflux in a diary.

When the patient returns the next day, the probe is removed. The data on the cassette are downloaded and put in graphic form. The data and the patients diary are then turned over to the gastroenterologist for an interpretation.

The codes for esophageal acid reflux tests, 91032 (esophagus, acid reflux test, with intraluminal pH electrode for detection of gastroesophageal reflux) and 91033 (prolonged recording), have a technical component and a professional component. In the Medicare Physicians Fee Schedule database, the relative value units (RVU) for each component are given in addition to the RVU for the full, unmodified code. The technical component is reported by attaching the modifier -TC to the code and the professional component by attaching modifier -26.

Reimbursement for the technical component is billed by the facility that owns the equipment, according to Cynthia Thompson, CPC, senior consultant with Gates, Moore & Co., a healthcare consulting firm in Atlanta. With esophageal acid reflux tests, the technical component consists of the insertion of the probe, the activation of the cassette, the downloading of the data from the cassette, and any instructions provided or questions answered by the person administering the test.

The gastroenterologist who reads and interprets the test bills the professional component, says Thompson. If the gastroenterologist owns the equipment used to administer the test and interprets the test results, he or
she can bill for both the technical and professional components of the procedure by reporting code 91032 or 91033 without a modifier. This unmodified code can be used regardless of whether the gastroenterologist, a nurse or a technician administers the test.

Code 24-hour Monitoring as Prolonged

Confusion also occurs concerning whether to report the base code 91032 or the prolonged recording code 91033, which has a significantly higher RVU. The general standard in esophageal acid reflux tests is 24-hour monitoring, according to Kathleen Maher, RN, clinical studies coordinator of the Esophageal/Motility Studies Laboratory at the Georgetown University Medical Center in Washington, D.C. Shorter periods can be used, but that happens infrequently, she adds.

Despite the fact that it is the norm, 24-hour monitoring should be reported using code 91033, states Devon Winborne, CPC, billing coordinator for the Gastroenterology Division at the Georgetown University Medical Center. Code 91032, which is bundled into the prolonged recording procedure, should not be reported in addition to code 91033 but can be used to report monitoring sessions of less than 24 hours. Winborne adds that supplies such as the probe used to do the monitoring are not reported separately at their practice.

Reporting Two Motility Studies on the Same Day

Esophageal manometry (91010) is another type of motility study used to diagnosis acid reflux and often is performed on the same day as a 24-hour pH monitoring, explains Maher.

When both procedures are performed on the same day, Winborne simply lists both of the codes on the claim form and doesnt attach any modifiers. He says that most payers will reimburse both procedures at their full value but admits that payment can vary significantly from payer to payer. Gastroenterologists should check with their local payers to get specific coding and payment information, however, because other coding experts attach either modifier -51 (multiple procedures) or -59 (distinct procedural service) to the lesser-valued procedure, which in this case is the manometry. These coding experts say reimbursement amounts also varied from the full value of each procedure to the full value of the highest-valued procedure (the pH monitoring) and 50 percent of the value of the lesser-valued procedure.

Occasionally, the tube that is passed into the esophagus wont clear, perhaps because of a hiatal hernia, Koch adds. The probe used to the do the pH monitoring must be inserted endoscopically with a guidewire. In that situation, the gastroenterologist would bill the appropriate endoscopy code in addition to the pH monitoring code.

Note: For more information on coding for esophageal manometry studies (code 91010), please read Interpret Esophageal Manometry Tests and Get Reimbursed on page 22 of the November 1999 issue of Gastroenterology Coding Alert.

Dont Confuse With Esophageal pH Monitoring

Many procedures listed in CPT look like esophageal pH monitoring and may be used to diagnose esophageal acid reflux but arent performed by gastroenterologists. When submitting a claim form, dont mistake the following tests for the 24-hour pH-monitoring test.

1. Modified barium swallow studies are studies of the esophagus that are performed by a radiologist, says Koch. The following CPT codes are included in this category:

70370 (radiologic examination; pharynx or larynx, including fluoroscopy and /or magnification technique)
70371 (complex dynamic pharyngeal and speech evaluation by cine or video recording)
74230 (swallowing function, pharynx and/or esophagus, with cineradiography and/or video)

2. Fiberoptic endoscopic evaluation of swallowing with sensory testing is an alternative to modified barium swallow studies for patients at risk for aspiration. They may be performed in conjunction with a speech pathologist and include the following codes:

31575 (laryngoscopy, flexible fiberoptic; diagnostic)
92520 (laryngeal function studies)
92525 (evaluation of swallowing and oral function for feeding)

Some gastroenterologists may just write acid reflux test in the patients medical record, which may not be enough to indicate to the billing office what procedure was done. If theres any question about what code should be used, the billing office should take the CPT book to the gastroenterologist and have him or her look at the CPT definitions for these procedures, says Thompson. The gastroenterologist needs to be specific about what was done and what definition is the best fit for the service provided.