Gastroenterology Coding Alert

Question: We recently started doing capsule endoscopies, but they-re being denied for diagnosis inconsistent with procedure. We do them for small bowel and were told that Florida Medicare was paying with a chronic iron-deficiency anemia diagnosis. Should I correct the claims with gastrointestinal bleeding (GIB) as the first diagnosis and chronic iron deficiency anemia (CIDA) as a secondary diagnosis? I have had a payer also split it to two line items and add modifiers 26 and TC and only pay me for 26. I appealed that we did both, and they denied my appeal. How can I prove that we own the equipment? Should the patients be signing advance beneficiary notices?


Florida Subscriber

Answer: Florida Medicare policy allows payment for GIB (578.9) but does not allow payment for CIDA. You should bill 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report) with no modifiers. As long as your place of service is the office and not outpatient at another facility, you should have no problems.

If you just can't get paid and should be, contact the carrier's reimbursement help department, and they should try to get it paid on an individual basis. The denial could be something as simple as being merely inappropriate.

You also need to be certain that your claims meet medical necessity. In some states, Medicare allows payment only for certain diagnoses. Be sure to check your local coverage determinations to find out which diagnoses your state carrier will pay.