Gastroenterology Coding Alert

Repeat studies demand this modifier.

When your gastroenterologist uses capsule study to obtain an image of the gastrointestinal tract, you can use two choices to report the procedure -- but there are a few rules to follow. Ask these three questions to perfect your capsule study claims. Hint: If you know how to distinguishing between 91110 and 91111 by telling what part of the anatomy your physician is visualizing or evaluating, then you're already one step ahead of the challenge.

You have two choices for coding this procedure:

• 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report), if your physician used the capsule study to image the intraluminal esophagus through the ileum (also including the stomach, duodenum, and jejunum)
• 91111 (Gastrointestinal tract imaging, intraluminal[e.g., capsule endoscopy], esophagus with physician interpretation and report), if your gastroenterologist performed imaging or study of the esophagus only, with interpretation and report

Difference: 91110 is the esophagus through the ileum and 91111 is esophagus only. You may rarely see the need to code 91111 because gastroenterologists do not routinely order the esophagus-only test opting instead to perform upper endoscopy.

Capsule endoscopy can be simple -- if you learn tactics from five of the most practical coder questions we have received.

1. How Do You Deal with Repeat Procedures?

Scenario: After the gastroenterologist has begun capsule endoscopy, the capsule got stuck in food on the fifth hour and she could see anything past the stomach. To resolve this, the gastroenterologist had to repeat the procedure to see if she could see the small and large intestine.

Code it: If your gastroenterologist is going to repeat the procedure, append modifier 53 (Discontinued procedure) to the first 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report).

Another option is just to leave the situation as it is, without repeating the procedure. In this case, you would append modifier 52 (Reduced services) to reflect that the capsule imaged the patient's anatomy until it became lodged in the food.

Rule of thumb: For 91110, the place of service should be where the capsule's data was downloaded. If your practice owns the equipment and capsule (and not a facility), indicate in your claim that your place of service was the office.

If a facility provided the capsule, you should append modifier 26 (Professional component) to 91110. This indicates that your office provided only the professional component of the service.

The facility will also code 91110 and append modifier TC (Technical component).

2. What Type of Disease Can a Cap Endoscopy Diagnose?

Capsule endoscopy is now seen as a sensitive and non-invasive means of examining the inside of the small intestine. Some common examples of small intestine diseases diagnosed by capsule endoscopy include:

• 569.84 -- Angiodysplasia of intestine (without hemorrhage)
• 555.9 -- Regional enteritis of unspecified site

Small intestinal tumors such as lymphoma (200-202), carcinoid tumor (209.00-209.03), and small intestinal cancer (152, Malignant neoplasm of small intestine, including duodenum)

3. What Are the Limitations of Capsule Endoscopy?

Despite most of gastroenterology practitioners acknowledging the capsule as the best means of viewing the inside of the small intestine, experts agree that problems in its use are inevitable.These are: It doesn't allow for therapy. The physician misses abnormalities in some areas of the intestine because of rapid transit of the capsule and blurred, uninterpretable photographs.

At times, transit is so slow that the capsule examines only part of the small intestine before the battery fails. If abnormalities are discovered that require surgical resection or further investigation, it may be difficult todetermine where in the small intestine the abnormality is.

The capsule can get stuck in the narrow area of scarring (strictures) or tumors in the small intestine and cause an obstruction of the intestine that requires surgical removal of the capsule.

Looking into the tens of thousands of photographs and analyzing each one of them consumes a huge portion of the physician's time.