Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a capsule endoscopy to get a closer look at the patient’s esophagus. I tried to report it using the newest capsule endoscopy code, 91113, but the payer denied the claim. I can’t use 0355T because 91113 replaced that code a while ago. So, which code should I be using for this procedure?

Ohio Subscriber

Answer: You’re correct that code 91113 (Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report) replaced deleted code 0355T, which used the same descriptor. However, the reason the payer denied the claim is because the gastroenterologist was looking at the esophagus, not the colon.

Which code to use for the procedure depends on the gastroenterologist’s notes. You will need to look at the specific capsule used and the portion of the GI tract the capsule took images from. For your situation, you’ll select either 91110 (Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report) or 91111 (Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with interpretation and report).

Coding alert: These codes are only applicable if the patient swallowed the capsule. If the patient is unable to swallow a capsule and the physician places it into the stomach or duodenum using endoscopic guidance, you can report 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)).

But be careful. Reporting that code is only correct if the physician performs a medically reasonable and necessary complete diagnostic upper gastrointestinal endoscopy procedure. You’ll need to append modifier 52 (Reduced services) with 43235 under those circumstances. Remember though that it requires submitting careful documentation to the payer to explain rationale and detail.