Gastroenterology Coding Alert

Revisions over the past two years to various CPT codes for H. pylori testing have created both confusion and challenges for gastroenterology coders. Depending on the gastroenterologist's preference and the patient's medical condition, coders need to know an array of codes in different sections of the CPT manual for accurate reporting and reimbursement of H. pylori testing.

The C-14 breath test is administered by giving the patient 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 is then exhaled and can be measured in the patient's breath. Ten minutes later, the patient provides a breath sample for analysis by blowing up a balloon. The sample can be sent to a testing laboratory, or the gastroenterologist can perform the analysis in-office using equipment called a liquid scintillation counter.
 
Administration of the C-14 breath test is reported with 78267 (Urea breath test, C-14; acquisition for analysis). If the gastroenterologist also performs the breath analysis, he or she uses 78268 ( analysis) for that step. If the breath sample is sent out for analysis, the laboratory reports the service with 78268.
 
But there are a few catches to coding for the microCOUNT analysis. Judy Burnett has nearly 20 years experience in gastroenterology coding, most of it with Asheville Gastroenterology in Asheville, N.C. Her practice installed the equipment as a convenience for patients.
 
"We use 78267 for administration of the test and 78268 for the analysis," Burnett says. "But we have to be careful with Medicare, because in our state we can't bill the breath test on the same day as the office visit. And with Medicaid, we can't have the test and the reading on the same day. As long as we're careful with those situations, we don't have any trouble with reimbursement."

Several revisions to CPT codes 83013 and 83014 in the past two years have broadened their usage. Code 83013 is defined as Helicobacter pylori; analysis for urease activity, non-radioactive isotope. Code 83014 is used to report the drug administration and sample collection.
 
References to breath specimens and mass spectrometry have been removed from the definition for 83013. These changes were made to allow the reporting of other methods that use the non-radioactive technology of the C-13 breath test, according to Joel V. Brill, MD, a gastroenterologist in Phoenix who is the American Gastroenterological Association representative to the CPT editorial advisory committee and the resource-based relative value scale (RBRVS) update committee.
 
"CPT codes 83013 and 83014 are used for H. pylori diagnostic tests, such as breath and blood specimens, that are based on C-13 technology for diagnosis," Brill says.
 
In the C-13 breath test, a baseline breath sample is collected and then the patient drinks a solution of carbon-urea in water. Subsequent breath samples are collected at timed intervals and typically sent to a laboratory for analysis.
 
Blood specimens can be tested for H. pylori with the same process used in C-13 breath tests. Use 83014 for the blood testing. This code is for administration of the test only. The laboratory or gastroenterologist, if applicable analyzing the blood sample should report 83013.

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 the presence of disease.
 
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 new code 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.
 
"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 explains. "Modifier -QW indicates that the analysis is a CLIA-waived test."
 
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 medical review policy (LMRP) of Empire Medicare, which covers New York, Connecticut, Delaware and Massachusetts:

Claims submitted for an unusual frequency of any of these services or services ordered for a diagnosis not listed as covered in this policy will be denied as not medically necessary in the absence of supportive documentation in the patient's record. H. Pylori tests done sooner than eight weeks from previous testing will be denied.

Check the LMRP of your state's Medicare carrier for similar restrictions.