Gastroenterology Coding Alert

Choose 91110 vs. 91111 based on the view.

If your gastroenterologist uses a capsule study to image the gastrointestinal track, there are two codes you could use to report the procedure. Learn how to distinguish between 91110 and 91111 by knowing what part of the anatomy your physician is visualizing or evaluating. Follow these tips to ensure you are coding correctly.

1. Identify Procedure Details to Determine Code Choice

Determining which code you'll report for a pill cam procedure, depends on the reason your gastroenterologist documents for performing the study.

How it works: If your physician used the capsule study to image the intraluminal esophagus through the ileum (also including the stomach, duodenum, and jejunum), you would report 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report).

When your gastroenterologist performs imaging or study of the esophagus only, with interpretation and report, you will use 91111 (Gastrointestinal tract imaging, intraluminal[e.g., capsule endoscopy], esophagus with physician interpretation and report) says Elaine Barnett, CPC, a charge specialist for Jefferson City Medical Group, in Jefferson City, Mo.

In other words: "The difference is 91110 is the esophagus through the ileum and 91111 is esophagus only," says Karen Lopinski, gastroenterology department billing coordinator at the University of Toledo Physicians in Ohio.

Watch out: Gastroenterologists do not routinely order the esophagus-only test because most payers will not cover 91111. For example, the only indication that Medicare carriers will cover is portal hypertension as the primary diagnosis and esophageal varices as the secondary diagnosis.

2. Turn to 52, 53 for Out of the Ordinary Procedures

You may need to append modifiers to the codes depending on the circumstances.Append modifier 52 (Reduced services) to 91110 depending on what the physician is able to see. "When using 91110, if the ileum is not visualized then that is when modifier 52 is necessary," says Lopinski.

There are other situations when you would need to use modifier 52. "This is particularly true if the gastroenterologist needs to repeat the study due to capsule retention in the stomach," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

Pointer: If your gastroenterologist aborted the procedure because the patient had trouble swallowing the capsule, you'll also turn to modifier 52.

If the capsule doesn't advance into the small intestine through the gastric outlet, however, you'll need to append 53 (Discontinued procedure) to 91110 since the purpose of this procedure is to view the areas of the small intestine beyond the reach of the normal endoscope. Most likely your gastroenterologist will repeat this study with the aid of an endoscope to place the capsule distal to the gastric outlet for visualization of the entire small intestinal tract.

3. Pay Attention to Surgical Location

Both 91110 and 91111 have technical and professional components. That means you may need to employ modifiers 26 (Professional component) and TC (Technical component) to accurately report the procedure your gastroenterologist performed.

Comprehensive option: If you're reporting both the technical and professional components -- for example, the physician doing the interpretation owns the equipment that was used to record the images -- then you would report either code without a modifier, Barnett says.

Alternative: If your gastroenterologist provides the pill cam capsule and owns the telemetry device then you would report either 91110 or 91111 without a modifier, explains Weinstein. "If your patient had the capsule procedure performed at an outpatient hospital or ambulatory facility then your gastroenterologist only reads the capsule video, the professional part of the procedure, and you'll need to append modifier 26," he adds. The outpatient facility will bill for technical component of the procedure and will append modifier TC to 91110 or 91111.