Gastroenterology Coding Alert

Question: Our physician places a capsule that we bought through our private practice and he brought over to the surgical center to place via endoscopy. We billed 43235 and 91110-52, and were paid. Later on, however, the insurance company notified us that they were taking back half of our payment on the 91110 stating we should have billed with modifier 26 as the hospital is billing for the same procedure code (91110). I think since we purchased the capsule and own the capsule equipment (belt, recorder and computer), we don't need the modifier 26, and the hospital should not bill for the capsule. Any insights?

Colorado Subscriber

Answer: You are correct. If your physician's private practice provided the capsule recorder belt and the capsule for your patient, and then your physician reviewed the belt recording on computer equipment in your office, then the hospital should not be billing the 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy, esophagus through ileum, with physician interpretation and report) capsule.

Someone at the hospital may have gotten confused because the patient had a capsule placed in their endoscopy suite and assumed that it was from hospital inventory. The hospital should only file a claim for the facility fee associated with the upper endoscopy. Your physician should file a claim for the endoscopy professional service and for 91110, indicating that your practice provided both the technical component and the professional reading service. You may need to contact the hospital to have them withdraw their claim for the technical component of the capsule study.