Radiology Coding Alert

Do not report 91111 in conjunction with 91110, 0355T.

Gastrointestinal imaging has undergone an evolution with the introduction of capsule endoscopy. Follow this direction to appropriately earn for capsule endoscopy, as this technique is increasingly being used in GI imaging.

Choose the Endoscopy Code According to Viewed Location

Your physician may perform a capsule endoscopy for diagnosing obscure gastrointestinal bleeding (bleeding of unknown origin) that is persistent or recurrent even after a negative initial upper GI endoscopy or colonoscopy. Diagnosis may be difficult because bleeding can often be slow and/or intermittent.

What causes bleeding in small intestine? Small intestinal bleeding can result from a number of conditions, including vascular lesions (angiodysplasia),small bowel tumors, celiac disease, and Crohn’s disease (which may be suspected because of other symptoms).

If the physician uses the intestinal capsule study to image the intraluminal esophagus all the way through the ileum, you should report code 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with interpretation and report).

Suppose the gastroenterologist limits her study to the patient’s esophagus only; then you should use the other capsule study code, 91111 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus with interpretation and report).

Documentation tip: “PillCam ESO® is the capsule used to perform a study limited to the esophagus. It has cameras facing in both directions in the capsule, takes more images per second, and has a shorter battery life,” informs Michael Weinstein, MD, vice president and member of the Board of Managers for Capital Digestive Care.

Note: Sometimes, the physician may suggest the use of an Agile® patencycapsule®. The patency capsule may be administered as a precursor to PillCam® to verify adequate patency of the GI tract before the actual use of the PillCam® in patients with known or suspected strictures. You should report 91299 (Unlisted diagnostic gastroenterology procedure) for this procedure.

Do not ignore 0355T: Effective July 1, 2014, CPT® has added a new code 0355T (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], colon, with interpretation and report) for intraluminal imaging of the colon, which you can report for these services.

Beware: Payers consider codes 91299 and 0355T as representing “investigational” procedures and will not cover them. As there are many variations among payers regarding the coverage of the procedures mentioned above, you’d be safe checking your individual carrier’s policies first before submitting your claim.

Turn to 52, 53 for Out of the Ordinary Procedures

You may need to append modifiers to the codes depending on the circumstances. Append modifier 52 (Reduced services) to 91110 depending on what the physician is able to see. When using 91110, if the ileum is not visualized, then turn to modifier 52.

There are other situations when you would need to use modifier 52, example, if your physician needs to repeat the study due to capsule retention in the stomach. Another example is when your physician aborted the imaging procedure because the patient had trouble swallowing the capsule.

If the capsule doesn’t advance into the small intestine through the gastric outlet, however, you’ll need to append 53 (Discontinued procedure) to 91110 since the purpose of this procedure is to view the areas of the small intestine beyond the reach of the normal endoscope.

Stay on the Right Side of Covered Diagnoses

Make sure that your physician has mentioned medical necessity of the procedure and codes the primary diagnosis to the highest level specified in the ICD-9. Some possible codes that you may encounter in the documentation:

»» 152.0-152.9 -- Malignant neoplasm of small intestine including duodenum

»» 209.0-209.7 -- Neuroendocrine tumors

»» 456.1 -- Esophageal varices without bleeding

»» 456.21 -- Esophageal varices without bleeding

»» 571.2 -- Alcoholic cirrhosis of liver

»» 571.5 -- Cirrhosis of liver without alcohol

»» 571.6 -- Biliary cirrhosis

»» 572.3 -- Portal hypertension

»» 555.0-555.9 -- Regional enteritis

»» 569.82 -- Ulceration of intestine

»» 569.84 -- Angiodysplasia of intestine (without hemorrhage)

»» 569.85 -- Angiodysplasia of intestine with hemorrhage

»» 569.86 -- Dieulafoy lesion (hemorrhagic) of intestine

»» 578.0 -- Hematemesis

»» 578.1 -- Blood in stool

Note: Please remember that capsule endoscopy is not covered for colorectal cancer screening.

Audit-Proof Your Capsule Endoscopy Notes

Your medical record should include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Do this: Keep copies of the video images with the beneficiary’s name and the date of service included in the picture.

Additional documentation that may be required for performing capsule endoscopy is:

If the patient shows GI blood loss or anemia secondary to the bleeding, you must include proof that the prior upper GI endoscopy or colonoscopy did not adequately reveal the source of bleeding.

•  If the physician recorded occult gastrointestinal bleeding without iron deficiency anemia, you must attach records of the presence of occult blood in fecal samples.
•  If the provisional diagnosis is Crohn’s disease, the physician should mark down the signs, symptoms, and previous diagnostic work supporting this diagnosis and that the patient does not have an  intestinal stricture. The physician also should add supporting diagnostic work if he suspects small bowel involvement.
• The medical record must document the need for capsule endoscopy and contain reports or reference to the previous appropriate negative endoscopies performed prior to endoscopy by capsule.