Gastroenterology Coding Alert

Question: We-re trying to get authorization from Aetna for the 24-hour pH study. We-ve used 91034, but Aetna denies the authorization request. Why? We-re using diagnosis code 530.11.

New Jersey Subscriber

Answer: Although you are correct to report 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation), your diagnosis of 530.11 (Reflux esophagitis) is the issue.

According to Aetna's Aug. 11, 2006, Clinical Policy Bulletin, this diagnosis is noncovered. If the gastroenterologist performs 91034, he should perform it based on the signs and symptoms of reflux esophagitis to detect or verify whether the patient has this condition. In other words, if you know the patient has reflux esophagitis, why are you performing the test?

Among those covered diagnoses listed are:

- 462 -- Acute pharyngitis

- 464.00 -- Acute laryngitis; without mention of  obstruction

- 472.1 -- Chronic pharyngitis

- 476.0 -- Chronic laryngitis

- 493.10 -- Intrinsic asthma; unspecified

- 530.81 -- Esophageal reflux

- 786.2 -- Symptoms involving respiratory system and other chest symptoms; cough

- 786.50 -- Chest pain, unspecified.

Bottom line: Until a test determines a condition, you should use signs-and-symptoms diagnoses rather than the ICD-9 code for the condition itself. Look to your gastroenterologist's documentation to make your code selection. If the signs and symptoms do not appear on your payer's covered diagnosis list, you may need to consider having the patient sign an advance beneficiary notice.

Don't forget: In most cases, when the gastroenterologist performs the pH study, he will leave the catheter in place for about a day, but you will claim 91034 (without a -reduced service- or -unusual service- modifier) regardless of how long the catheter remains in place. This differs from past practice, in which you had to distinguish between standard and -extended- pH monitoring.

For example: For pH testing lasting six hours using a nasal catheter, you would report 91034. If the physician leaves the catheter in place for 24 hours, however, the coding would be the same.