FAQS to Help You Choose the Right Code

Do you know how to bill your claim when a patient presents to your office for a capsule study and the capsule gets lodged in his stomach?

If you have a good sense of what anatomy the capsule study evaluates, it could save you from a possible coding disaster. It is not enough that you know the two CPTs (91110 and 91111) to use for this study.

Here are some answers to frequently asked questions (FAQs) which will help you in choosing the right code:

How would you code a repeat procedure with 91110?

Now and then, your gastroenterologist would use a capsule study to image the intraluminal esophagus all the way through the ileum and reaching the colon. Here, you should report 91110 (Gastrointestinal tract imaging, intraluminal [example, capsule endoscopy], esophagus through ileum, with physician interpretation and report).

For instance: Patient comes in for a capsule endoscopy; however the capsule gets stuck and visuals can't be seen past the stomach. The gastroenterologist ends up repeating the procedure to see if she can see the small and large intestine.

Report it: Initially you would code 91110 and then add modifier 53 (Discontinued procedure) to indicate that the doctor repeated the procedure. If the physician makes up his mind not to repeat the procedure, you should go for modifier 52 (Reduced Services) to mirror that the capsule imaged the patient's anatomy until it became lodged in the food.

Medical coding tip: If you think about repeating a capsule study owing to technical problems, it's a good idea to pre-authorize payment for the second study with the carrier. You may be required to provide records of the incomplete study.

According to CPT 91110's descriptor, the evaluation is from the esophagus to the ileum. The only time this won't be true is when the gastroenterologist places the pill cam endoscopically for the study. Once again in this case, you should use modifier 52 to 91110.

What does 'SB' (small bowel) and 'ESO' mean on PillCam Labels?

Imagine that the gastroenterologist limits her study to the patient's esophagus only – without going further down the stomach, duodenum, jejunum and ileum. Here, you should go for the other capsule study code: 91111 (Gastrointestinal tract imaging, intraluminal [example., capsule endoscopy], esophagus with physician interpretation and report).

Notice that the physician would use two different types of wireless capsules when performing 91110 and 91111, respectively. PillCam SB is designed specifically to visualize the esophagus, stomach, duodenum, jejunum, and ileum. It has one camera and a battery that can last up to eight hours. In contrast, PillCam ESO covers the esophagus. It has cameras at both ends of the capsules and takes very rapid images; however the battery lasts only for a short while.

Tread cautiously: Do not dare to report 91110 and 91111 together as the work required in 91111 is already included in 91110, according to CCI edits. As some payers consider PillCam ESO “investigational, and will not cover the procedure, you would be safe checking your payer's policies first prior to submitting your claim.

Where PC and TC matter

In many areas, hospital endoscopy suites purchase the capsules, and hospitals own the equipment used to view the capsule video. If the physician provides only the professional portion of the procedure ( i.e interpretation and report of the results) , you should use modifier 26 (PC) to the CPT Codes. Do not worry about adding any modifiers if the physician purchases the capsule and owns the computer video equipment. In that case the physician provides both the PC and TC of the procedure.

Advice: Ensure you maintain proper clinical and billing records in case the payer elects to audit claims.