Wiki Incomplete Capsule 91110-Mod 52 or 53

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debemrxs4@aol.com

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Need some advise on Incomplete--Capsule Endoscopy's done in the office.----Let me explain.

I've been coding my incomplete Capsules Endoscopy's done in the office with Modifier 53 thinking that this was appropriate because my provider speaks about how it does not enter the cecum on the study, however, I have received quite a few denials from MEDICARE which has prompted me to do a lot of research on this--SHOULD I BE CODING THESE WITH MODIFIER 52??????

I asked my provider if when he states that the capsule did not enter the cecum, does that mean that the ileum was not visualized? His answer to me was that it is incomplete and this can be interpreted as the ileum not visualized, however, part of the ileum-may have been seen as he doesn't know the extent the capsule got down.

Here's a summary of what a report reads:

PROCEDURES INFORMATION and FINDINGS
Pillcam was swallowed w/o difficulty. Esophagus w/limited views. Pillcam remained in stomach for what seems like the entire study. Patient ate during the study which obscured the views of surrounding mucosa to distinguish if it had entered into the duodenum.
One or two angioectasias in the stomach were seen in this study with some blood.
Pillcam did NOT obviously enter small bowel or cecum on this study.

SUMMARY and RECOMMENDATIONS
Incomplete study w/prolonged gastric emptying time.
Given that there was one or two angioectasias identified in the stomach with bleeding,
Would suggest re-deployment of capsule following 24 hour liquid diet and 8 hours of NPO while study is active, perhaps endoscopically.
Perform XRAY 3 weeks after this study completed to ensure passage of capsule.

I would appreciate any of your help and any resources you might have.

Thank you!
 
Hello, yes I have looked at the LCD policy and the dx's billed are on the covered list---for ex D50.9, however, the denial for the above report states, "records do not support service billed. Not well documented, it also stated that provider signature not legible, which we had provider do an attestation for. (we are in process of have electronic signatures set up) I billed the Mod -53 which, I'm thinking should have been billed with a Mod 52???
 
The CPT book does say to use 52 if the ileum is not seen - but I've been using 53 if the plan is to do another one and 52 if it won't be and have not had a problem. I do include a short description on the claim in box 19 to ID the issue. Per the denial it sounds like his documentation is lacking. I have in my personal notes that the report must specifically state whether or not the ileum was seen - maybe the problem is that his note is not clear enough. If your other denials are for the same reason maybe comparing his notes will give you a definitive answer. Hope that helps.
 
Hello, I was wondering when you bill for this does your office download the pillcam footage or do you have to send it out? Im asking because im trying to figure out if I bill for TC and 26 or not. We do give the pill in office and the Dr does review the results but we do send it out and have the imaging sent to us.
 
I don't honestly know if we download the images ourselves (I think we do, but not certain). If your company owns the capsules and your providers read them wouldn't you bill globally?
 
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