Part B Insider (Multispecialty) Coding Alert

Hint: Obtain prior pre-authorization to avoid payer denials.

You can improve your CPT^® 2013 code 91112 claims success if you , focus on whether or not the procedure was complete and concentrate on who owns the equipment for the procedure.  These codes replaced the former Category III codes 0242T.

Check Payer Rules for 91112

Your gastroenterologist might perform a wireless capsule test for gastrointestinal pressure and transit measurement in many motility disorders of the GI tract. Your gastroenterologist may use this method to check gastric emptying in patients suspected to be suffering from gastroparesis. Or your physician may use this to investigate chronic constipation causes or other intestinal motility disorders. When your gastroenterologist performs a wireless capsule test for GI pressure and transit measurement, you will report the procedure and the interpretation of results using 91112 (Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report).

Caveat: Many payers still consider the procedure of using a wireless capsule to measure GI pressure and transit as investigational and might not provide coverage for the procedure. Many payers also mention that this procedure needs pre-authorization, so check with payers’ coverage policies to avoid the risk of denials. “We were often frustrated with payment denials last year because most commercial carriers consider the CPT III codes not just new technology but experimental services and not reimbursable.  With the new permanent code we believe this new technology will be able to replace older tools that were less sensitive and specific for digestive tract motility disturbances,” says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT^® Advisory Panel. 

Append Suitable Modifiers for Discontinued Procedures

Your gastroenterologist may attempt a capsule study for pressure and transit measurement but may need to discontinue the procedure. One such scenario is when the patient has difficulty swallowing the capsule. In such a situation, you will have to append modifier 53 (Discontinued procedure) to 91112 to indicate the incomplete work. Another situation that warrants you to report this modifier is when the capsule gets retained in the stomach.

If your gastroenterologist repeats the procedure by placing the capsule endoscopically in the duodenum for the repeat procedure, then you need to report the procedure using 91112 and the modifier 52 (Reduced services) to the code to indicate that your gastroenterologist used the wireless capsule to measure pressure and transit in the areas beyond the stomach.

Reminder: Don’t forget to report the endoscopy that your gastroenterologist performed to place the capsule. You will have to report it with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Coding scenario: Your gastroenterologist assesses a 63-year-old patient with problems of chronic constipation that has not been relieved by lifestyle changes and previously prescribed medications. Your gastroenterologist decides to perform colon motility studies using the SmartPill wireless capsule. The patient ingests the capsule using water. The capsule gets stuck in food on hour five.

Your gastroenterologist decides to discontinue the procedure and place the capsule endoscopically. You report 91112 with the modifier 53 to indicate that your gastroenterologist had to abort the procedure. You report the second procedure with the modifier 52 (as the capsule was placed beyond the stomach) and report 43235 for the EGD that was used to place the capsule endoscopically.

Don’t Report Other Motility Studies With 91112

Your gastroenterologist might use other means to check for GI pressure and transit measurements. He might resort to using radiopharmaceuticals or insert a tube into the GI tract to check for these parameters. When methods other than a wireless capsule are  used to capture the parameters of pressure and transit or to check for motility disorders, you will have to report it depending on the anatomical location using 91020 (Gastric motility [manometric] studies), 91022 (Duodenalmotility [manometric] studies) or 91117 (Colon motility [manometric] study, minimum 6 hours continuous recording [including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed], with interpretation and report).

Separate Components When Appropriate

When reporting 91112 for GI transit and pressure measurements, you will have to check who owns the equipment that is being used. If your gastroenterologist owns the recording device and provides the capsule for the procedure, you will just have to report the entire procedure and the interpretations along with the report using 91112.

However, if your gastroenterologist is only providing interpretations and prepares the report for the GI transit and pressure measurements, and the hospital owns the equipment, you will have to report components of 91112 separately. In such a scenario, you will have to report the services of your gastroenterologist using 91112 with the modifier 26 (Professional component) and the hospital will report its part using 91112 with the modifier TC (Technical component).