Capsule Endoscopy Coding, Made Simple
Correctly coding this diagnostic service depends on what’s viewed.
By G.J. Verhovshek, MA, CPC
Capsule endoscopy is an alternative to traditional endoscopy that uses a tiny camera contained within a pill that the patient swallows to obtain images of the interior of the digestive tract (for instance, to diagnose polyps or the source of bleeding). Unlike colonoscopy or esophagogastroduodenoscopy (EGD), however, capsule endoscopy is purely diagnostic. The best known capsule endoscopy devices are marketed under the name PillCam™.
Coding for capsule endoscopy depends on which structures the physician wishes to view.
- For imaging of the esophagus only, using a PillCam ESO or similar Food and Drug Administration (FDA)-approved device, the correct CPT® code is 91111 Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus with physician interpretation and report. In this application, the camera may transmit up to 15 diagnostic images per second as it travels down the esophagus.
- For imaging of the gastrointestinal (GI) tract from the esophagus to the ileum, using a PillCam SB or similar FDA-approved device, you should assign CPT® 91110 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with physician interpretation and report. Over the course of approximately eight hours, the capsule moves through the digestive tract, transmitting pictures on average every two seconds. This type of capsule endoscopy allows for imaging of the small bowel, which is not possible with colonoscopy or EGD. Visualization of the colon is not reported separately with 91110, according to CPT® instructions.
Do not report 91111 in addition to 91110. As a more extensive procedure, 91110 includes 91111, per CPT® instructions and National Correct Coding Initiative (NCCI) bundling edits.
Modifiers May Be Necessary for Unusual Circumstances
Reporting capsule endoscopy is usually straightforward, but sometimes there are circumstances that call for a modifier.
For example, according to CPT®, when reporting 91110, modifier 52 Reduced services is required when the entire distance from the esophagus to the ileum is not visualized. For instance, the physician may place the capsule endoscopically, so the esophagus and stomach are not imaged. Or, the camera may become obscured by food when it reaches the stomach, and no further images are recovered. In either case, it would be appropriate to report 91110-52.
If images are not recovered due to technical problems (such as the camera being obscured by food in the stomach, as in the above example), the physician may wish to repeat the study to gather necessary images. In such cases, it is wise to contact the payer for reauthorization of the procedure. In some cases, payers will allow you to report the failed procedure as 91110-53 Discontinued procedure.
Note: Some payers consider capsule study of the esophagus (91111) to be experimental and not a covered procedure. Speak with your payer for coverage details.
Note also: CPT® codes 91110 and 91111 include both technical and professional components. Often, the hospital or endoscopy suite will purchase the capsule (which is used only once) and the necessary equipment to receive and view the images it captures. When this occurs, the physician who interprets the images may claim only the professional portion of the service (e.g., 91110-26 Professional component). If the physician supplies the capsule and related equipment, you may report the global service with no modifiers appended.
Call on 0242T for Pressure Measurements
Wireless capsules, similar (but not identical) to those used for capsule endoscopy, may be used to measure GI tract transit times and/or pressure to evaluate patients with suspected gastroparesis, slow transit constipation, unexplained diarrhea, or functional constipation that may be due to GI tract mobility issues. To report such studies, turn to Category III code 0242T Gastrointestinal tract transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report.
Do not report 0242T in addition to 91020 Gastric motility (manometric) studies or 91022 Duodenal motility (manometric) study. Codes 91020 and 91022 “are inappropriate for identifying the study of motility of the small intestine distal to the duodenum or the colon or serial examination of this nature performed in conjunction with gastric and/or duodenal motility,” according to the American Medical Association’s CPT® Changes 2011: An Insider’s View.