Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed capsule endoscopy but the capsule did not leave the stomach. So he is planning to repeat the procedure by placing the capsule directly in the duodenum endoscopically for the second procedure. How do we report both these procedures?

Nebraska Subscriber

Answer: When your gastroenterologist uses capsule endoscopy to view the gastrointestinal tract from the esophagus to the ileum, you will need to report the procedure using 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report). However, if the procedure had to be discontinued as the capsule got stuck in the food in the stomach, you will need to use the modifier 53 (Discontinued procedure) to 91110 to indicate that your gastroenterologist was not able to view the entire gastrointestinal tract till the ileum.

If your gastroenterologist repeats the procedure by placing the capsule endoscopically in the duodenum for the repeat procedure, then you need to report the procedure using 91110 and the modifier 52 (Reduced services) to the code to indicate that your gastroenterologist used the capsule endoscopy to view the digestive tracts from the duodenum to the ileum.

It is always best that you try to get a pre-authorization for the second capsule study done within a short timeframe due to malfunction or stomach retention. You will need to submit the documentation for the previous study that was discontinued because the capsule became stuck with food in the stomach.