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Gastroenterology Coding Alert

Reflux Test Redux:

Report Procedure With 1 Code in 2005

Published on Sat Feb 05, 2005

Also, include documentation of other treatments doctor tried

If you're now reporting gastroesophageal reflux tests the same way you did in 2004, you should be on the lookout for possible denials for these claims.

Why? CPT changed the reporting rules for reflux tests. From now on, when the gastro performs a reflux test and reading lasting less than 24 hours, you should use new code 91034 to report the service.
 
Read on for a rehash on what goes into a really fine reflux test claim.

Use 91034 Regardless of Time

The old method for reporting reflux tests relied on a pair of codes. Before 2005, coders reported reflux tests with 91032 (Esophagus, acid reflux test, with intraluminal pH electrode for detection of gastroesophageal reflux) and 91033 (... prolonged reading), depending on the encounter. CPT does not include either of these codes in its latest manual, so you should forget that they ever existed.

Now you should report reflux tests with 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation), said Robert B. Cameron, MD, FACG, of the American College of Gastroenterology and the AMA/CPT Advisory Committee, during November's CPT 2005 Coding Symposium in Chicago.

The 91034 code covers pH electrode placement "that ideally will record esophageal pH for a 24-hour period or less," Cameron said.

Heartburn, Asthma May Prompt Reflux Test

As an illustration of how to use code 91034, consider this example. A patient with a history of heartburn reports with severe heartburn six weeks after his last appointment, during which the gastroenterologist had recommended some lifestyle changes aimed at reducing the heartburn.

The patient reports that the changes have failed to stop the heartburn, so the gastro performs a gastroesophageal reflux test, recording the patient's esophageal pH for 10 hours.

On this claim, you should:
 

  •  report 91034 for the reflux test with a date of service that reflects the day the gastro collected the data.
     
  • attach ICD-9 code 787.1 (Heartburn) to 91034 to prove medical necessity.
     
  •  include documentation that explains other courses of treatment the physician attempted before the reflux test. (In this case, the notes should include the lifestyle changes the gastro recommended to the patient, evidence of the lifestyle changes' ineffectiveness, and any other actions the gastro took to combat the heartburn).

    Other acceptable diagnoses:

    While this is not a complete list, other ICD-9 codes that may prove medical necessity for 91034 include:  

  •  493.82 - Cough variant asthma
     
  •  530.10 - Esophagitis, unspecified
     
  •  530.2x - Ulcer of esophagus
     
  •  530.85 - Barrett's esophagus
     
  •  786.2 - Cough
     
  •  786.59 - Chest pain; other.

    Remember: Most payers consider these ICD-9 codes acceptable diagnoses for reflux tests, but your carrier may not. If you are unsure about the appropriateness of an ICD-9 code, double-check your contract - or call the payer and ask.

    Don't Skimp on Other Therapies

    When you're reporting a reflux test, experts strongly suggest that you include evidence of other treatments your gastro tried before the test. This evidence can be as important to your claim as the right CPT code, says Lisa Kools, administrator for Digestive Healthcare Specialists in Oshkosh, Wis.

    Why must you record other treatments? The patient's diagnosis or chief complaint may not be what drives the gastro to test for reflux. The gastro may decide on the test based on other factors, Kools says.
     
    Some of these factors could be:  

  •  Has the patient been tried and failed on proton pump inhibitors?
     
  •  Have lifestyle modifications failed to improve patient symptoms?

  •  Is the patient being considered for a Nissen fundoplication?

    Experts agree that on 91034 claims, you can't have too much documentation. You should list every therapy and treatment the gastro attempted, says Kimberly Green, CPC, project coordinator with University of Pittsburgh Physicians.

    To illustrate her point, Green lays out her Medicare carrier's tricky policy on reporting 91034 to test for gastroesophageal reflux disease (GERD, ICD-9 code 530.81, Esophageal reflux). 

    Medicare covers 91034 "for patients who are suspected of having GERD, but only if the patient presents diagnostic symptoms associated with atypical symptoms, or if the patient's symptoms are suggestive of reflux but conventional tests have not confirmed the presence of GERD," Green says.

    Consequence: If you do not include evidence that the gastro performed conventional tests to check for GERD before choosing to perform a reflux test, the claim may fail.

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