Gastroenterology Coding Alert

Gain some incident-to insight as well.

Gastroesophageal reflux disease (GERD) is something gastroenterology coders see regularly. While coding the diagnosis itself might seem straightforward, it may be more challenging to code diagnostic tests like esophageal motility studies. To avoid miscoding, we’ve busted a few common myths to get your motility coding back on track.

Myth 1: 91010 is the Go-To Code for Esophageal Testing

While it’s true that 91010 (Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report) is the code you’d report if the gastroenterologist utilized esophageal manometry such as a “manometry nasal catheter” with pressure readings, it’s by no means the default code to use for all esophageal testing.

Another test that your gastroenterologist often performs while assessing a patient with suspected GERD is pH monitoring, typically over a 24-hour period, using a pH probe placed through a nasal catheter. Such pH studies should be reported with 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation).

Example: Your gastroenterologist sees a patient suffering from recurrent heartburn. Lifestyle changes and acid suppression medications prescribed six weeks prior are not improving symptoms. The provider instructs the patient to stop medications for one week and orders a pH monitoring test. A pH monitoring probe is inserted using an intranasal catheter and the recorder attached to the other end of the probe is activated to capture the data. The GI physician asks the patient to return after 24 hours. Upon return, your gastroenterologist retrieves the data for interpretations. Report this procedure with 91034.

Coding alert: If your gastroenterologist opts for motility studies described by 91010, they might use a medication stimulant. If that’s the case, you’ll need to report the additional procedure with add-on code +91013 (Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with stimulation or perfusion (eg, stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedure)).

Myth 2: There’s No Way to Code for Motility Testing Done in a Hospital

This is a common misconception because some gastroenterologists practice in a hospital rather than a standard outpatient facility. In those cases, the gastroenterologist does not own the equipment for the motility tests, so you’ll have to separate the technical and professional components. For example, you’ll report 91010 with modifier 26 (Professional component) to claim the professional component of the service. The facility will bill the same code with modifier TC (Technical component …).

However, if your gastroenterologist owns the equipment, then you should stick to the appropriate test codes and bill globally without applying any modifiers. The value of the code includes payment for both the professional and technical components.

Myth 3: An NP Can Always Bill Incident To for Routine GERD Follow-Ups

An NP can often bill incident to for routine GERD follow-ups, but not always. That’s generally because of how frequently patients come into their follow-up visits with new problems.

Consider this example: A physician sees a patient for elevated blood pressure and GERD and wants the patient to be seen every three months. The patient returns at three-month intervals and is seen by the nurse practitioner (NP) for these distinct problems under the physician’s plan of care. The NP’s services are billed by the supervising physician under the incident-to guidelines.

If the established patient who returned in three months now has a complaint of rectal pain in addition to the management of their GERD and elevated blood pressure, they could not be seen incident to by the NP since there is a new problem. But since they are scheduled with the NP, they could be seen by the NP and the service can be billed under the NP’s NPI, for which Medicare will allow 85 percent of the physician fee schedule amount.

Although incident-to care covers a wide range of services in the office, one thing it doesn’t cover is a new patient visit or a visit to address a new problem, said Christine Obergfell, NGS Provider Outreach and Education Consultant, during the Part B payer’s webinar, “Incident To Made Simple.”

“An initial history and physical performed by a nonphysician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the incident-to guidelines,” she said.

That’s because under Medicare’s incident-to guidelines, the physician must perform the initial service and establish a plan of care. “This includes the history and physical examination portion of the service and the treatment plan,” she said. “It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship,” if the NPP will be billing incident to.

Myth 4: Endoscopy Will Always Be Reported Separately

This is another case of sometimes versus always. For example, if the doctor suspects GERD and does an endoscopy to get a closer look, you can report it with the appropriate code for the endoscopy such as 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).

However, the gastroenterologist may also wish to place a Bravo capsule — a catheter-free pH monitoring system the size of a gel cap that temporarily attaches to the wall of the patient’s esophagus. The capsule transmits pH information wirelessly to a portable receiver worn on a waistband. Report this procedure with 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation). To insert the Bravo capsule, it is necessary to know the distance from the teeth to the lower esophageal sphincter. Therefore, your gastroenterologist might need to perform endoscopy on the day of the Bravo insertion if the distance is not known from a prior endoscopy. If the sole purpose of the endoscopy is to place the Bravo capsule, then the endoscopy should not be reported separately.

Coding alert: If it is medically necessary to perform an EGD to evaluate the symptoms in addition to determining the location for placement of the capsule, then both procedures (EGD and Bravo capsule) can be billed. In this scenario, you would bill the EGD on the date of service of the endoscopy, with the appropriate symptom code (such as K21.9, Gastro-esophageal reflux disease without esophagitis). Then, bill 91035 for the day the doctor interpreted the test, which is typically 48 to 72 hours later. However, “if the hospital outpatient department furnished the Bravo capsule and equipment to do the analysis, the physician would only report 91035 with the 26 modifier for the professional component,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.