Gastroenterology Coding Alert

To appropriately report Helicobacter pylori (H. pylori), you must turn to an array of codes in different sections of the CPT manual. Our experts break down your coding choices and show that your selection will depend on the gastroenterologist's preference and the patient's medical condition.

First of all, take a look at C-14 breath tests.

What happens: The patient takes a capsule containing carbon-urea with a low dosage of a radioactive material. If H. pylori is present, it breaks down the urea into carbon dioxide, which the patient then exhales. The gastroenterologist can then measure it in the patient's breath. Ten minutes later, the patient provides a breath sample for analysis by blowing up a balloon. A testing laboratory or the gastroenterologist can perform the analysis in-office using equipment called a liquid scintillation counter.

You should report the administration of the C-14 breath test with 78267 (Urea breath test, C-14 [isotopic]; acquisition for analysis). If the gastroenterologist also performs the breath analysis, you should report 78268 (... analysis) for that step. Watch out: If the physician sends the breath sample out for analysis, the laboratory reports the service with 78268.

Beware: You might need to be careful reporting an office visit and the breath test on the same day. "It's the usual issue," says Marvel J. Hammer, RN, CPC, CSS-P, ACS-PM, CHCO, with MJH Consulting in Denver. You can report an E/M code only if the physician's documentation supports that the E/M service meets the medical necessity and was more than just the administration and/or analysis of the diagnostic test.

In other words, you cannot report an E/M service (such as 99211, Office or other outpatient visit ...) if the patient is merely taking the breath test. You should include the nonphysician work of acquisition and/or analysis in 78267-78268.

Don't forget: If your practice provides the radioactive isotope for this procedure, you should include A4641 (Radiopharmaceutical, diagnostic, not otherwise classified).

For non-radioactive technology of the C-13 breath test, you should use 83013 (Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope [e.g., C-13]) and 83014 (... drug administration).

You should use 83013 and 83014 "for H. pylori diagnostic tests, such as breath and blood specimens, that are based on C-13 technology for diagnosis," says Joel V. Brill, MD, AGAF, chief medical officer at Predictive Health LLC in Phoenix.

What happens: In the C-13 breath test, the physician collects a baseline breath sample, and then the patient drinks a solution of carbon-urea in water. The physician collects subsequent breath samples at timed intervals and typically sends them to a laboratory for analysis.

Note: Blood specimens can be tested for H. pylori. Use 83009 (Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope [e.g., C-13]) for the blood testing. Code 83014 is only for administration of the test.

Testing for H. pylori with a stool sample is reported with 87338 (Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; helicobacter pylori, stool).

Gastroenterologists often choose endoscopy with biopsy and perform a campylobacter-like organism (CLO) test during the procedure to determine H. pylori infection and disease presence.

What to do: The first step is to report the endoscopy with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple). Then use 87077 (Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate) to report the examination of the biopsied specimens.

Be sure to append this code with modifier QW (CLIA waived test). Why: "Use 87077-QW to indicate a culture or direct bacterial analysis by a commercial kit such as the rapid urease test or CLO test," Brill says.

  Note: CLIA refers to Medicare's Clinical Laboratory Improvement Amendments. Tests that are CLIA-waived are determined by the Food and Drug Administration or Centers for Disease Control and Prevention to be so simple that there is little risk of error in the analysis.

Many Medicare carriers have guidelines for the frequency of billing for this testing. Here's an example from the local coverage determination (LCD) of National Government Services Inc. (formerly known as Empire Medicare), which covers downstate New York:

Once positive, serology for H. pylori will only be paid one (1) time, since the presence of antibodies can persist for a long period of time. Therefore, a repeat of this test will be subject to review.

Best advice: Check the LCD of your state's Medicare carrier for similar restrictions.