Gastroenterology Coding Alert

Find out why modifiers are out of the question for 91034.

Whether your gastroenterologist refers to it as "acid reflux study" or "gastric motility study," she means the same diagnostic test for gastroesophageal reflux disease (GERD). But other terms, such as "pH monitoring" and "gastric/esophageal manometry" prove to be as promising.

Examine the following truths and fallacies surrounding GERD diagnostic testing, and be able to make the proper distinction.

1. 'Motility' Links with Esophageal Manometry

Truth. If the physician performs an esophageal "motility study," you have three codes to choose from. They are:

• 91010 -- Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study
• 91011 -- ... with mecholyl or similar stimulant
• 91012 -- ... with acid perfusion studies.

Gastroenterologists have become more familiar with these esophageal manometry codes (91010-91012) since the procedure has become standard prior to surgery for GERD (530.81). CPT 91011 describes the basic test plus administration of a stimulant (to increase motility), while 91012 describes acid perfusion study in addition to the motility study.

What takes place: Esophageal manometry is a gastric motility test used to evaluate neuromuscular disorders of the esophagus. The physician passes a manometry catheter through the nose into the esophagus. The catheter connects to a computer, which records the pressure waves of the esophagus during swallowing. These pressure readings, which should appear on the physician's notes, will give you a clue on the procedure.

2. Standard pH Test Coding Calls for Various CPTs

Fallacy. Only one CPT applies for an esophageal acid reflux test using either a disposable or a reusable nasal catheter, and that is 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation), according to Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

Whether the physician leaves the catheter in place for about a day or shorter, you should code 91034 without appending a "reduced service" or "unusual service" modifier. In the past, you would report reflux tests with 91032 (Esophagus, acid reflux test, with intraluminal pH electrode for detection of gastroesophageal reflux) and 91033 (... prolonged reading), depending on the encounter. Today, you should stick with 91034 regardless of time.

The 91034 code covers pH electrode placement "that ideally will record esophageal pH for a 24-hour period or less," says Robert B. Cameron, MD, FACG, of the American College of Gastroenterology.

Example: A patient with a history of heartburn reports with severe heartburn six weeks after his last appointment, during which the gastroenterologist had recommended some lifestyle changes aimed at reducing the heartburn. The patient reports that the changes have failed to stop the heartburn, so the gastro performs a gastroesophageal reflux test, recording the patient's esophageal pH for 10 hours.

On this claim, you should report 91034 for the reflux test with a date of service that reflects the day the gastro collected the data. You should also attach 787.1 (Heartburn) to 91034 for medical necessity.

Important: Make sure you include documentation that explains other methods of treatment that they physician tried before opting for the pH test (for instance, lifestyle changes recommendation to the patient, and why it failed).

3. Use a Different CPT for pH Testing with Bravo Capsule

Truth. If the pH test goes beyond a standard probe, and uses a Bravo capsule, you would use 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation) instead of 91034.

Purpose: This test involves the physician placing the capsule using an endoscope, which you may report separately in some circumstances. The use of the Bravo capsule has advantages over a standard catheter pH study, such as providing greater patient comfort, and being able to monitor pH levels over a longer time period.

Example: A patient with a history of reflux esophagitis reports to your office. The gastroenterologist performs an esophagogastroduodenoscopy (EGD) and takes a biopsy, determines the location of the lower esophageal sphincter and inserts a Bravo capsule using the delivery catheter several centimeters above the sphincter. First, you should claim 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) for the EGD. Then, report 91035 if the gastroesophageal reflux test includes a Bravo capsule insertion during the same session. For this CPT, use the date of service that reflects the day the gastro collected the data recorder. Lastly, you should not forget to append 530.11 (Reflux esophagitis) to both 43239 and 91035 to prove medical necessity.

Tackle Multiple Test Scenario

How would you report a physician performing manometry and pH study for the same patient on the same date? Simply code the procedures separately and expect separate reimbursement without using any modifier to separate the services.

Alternative: You may report the manometry on the day the test was performed. For the pH study, use the date of service as the day the test is completed.

Example: The physician performs manometry on a patient on Tuesday. She places the probe for 24-hour pH study. The patient returns on Wednesday to complete the pH study. For Tuesday's visit, you would code 91010, along with any significant, separately identifiable E/M service. For Wednesday's pH study, you would report either 91034 or 91035, depending on the method.

Aid Your Claim with Modifier 25 for Unplanned Tests Sometimes the physician decides to perform motility or pH study spontaneously during a patient's visit, after rendering a significant, separate E/M service on the same date of service.

How should you report it? See in this 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.

Code it: Report 99202 (Office or other outpatient visit for the evaluation and management of a new patient...) for the E/M service, with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service) attached. In addition, report 91010 to report the manometry and 91034 to report the standard pH test with the date of service on the day the data was collected.