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Gastroenterology Coding Alert

Check Reflux Reports for Manometry, Bravo Procedures

Published on Sat Feb 05, 2005

Sometimes, a reflux test is only half the claim

When your gastro administers a reflux test and inserts a Bravo capsule during the same session or checks for reflux and performs an esophageal manometry, you should not report either of these procedures the same way you did in 2004.

To be compliant when reporting these test combinations in 2005, you'll have to learn a few new tricks (and forget some old ones). We'll examine each of these multiple-procedure scenarios and get some expert advice on how to make your reflux claim reflect rock-solid medical care.

New Code Reflects Bravo Cap/Reflux Combo

If the gastroesophageal reflux test includes a Bravo capsule insertion during the same session, you should now use CPT 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation).

When would the doctor do this? There are several occasions when a physician might opt to perform a Bravo insertion and a reflux test during the same session, says Cheryl Pistone, director of clinical services at Consultants in Gastroenterology in Independence, Mo.

Some physicians insert the Bravo cap over a standard pH probe "because you can insert the capsule so it can't be seen outside the body, so patients can go about their normal days. Also, you can get 48 hours of information as opposed to only 24 hours, as would be the case with the standard pH probe," Pistone says.

Yes, You Can Still Report Pre-Bravo EGD

When a gastroenterologist inserts a Bravo capsule, he must first perform an upper gastrointestinal endoscopy (EGD) on the patient to "determine how far down to place the Bravo cap," says Kimberly Green, CPC, project coordinator at University of Pittsburgh Physicians. Sometimes, the EGD is diagnostic; other times, the gastro takes a biopsy, she says.

Example: A patient with a history of reflux esophagitis reports to your office. The gastroenterologist performs an EGD and takes a biopsy, administers the reflux test and inserts a Bravo capsule. On your claim, you should:
 

  •  report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) for the EGD
     
  •  report 91035 for the reflux test with Bravo device
     
  •  attach 530.11 (Reflux esophagitis) to both 43239 and 91035 to prove medical necessity for the procedures.

    Service-date alert: When reporting 91035, the date of service should be the date the gastro retrieves the data collection recorder.

    Exception: In the above example, if the gastro did not take a biopsy, you would report 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]) for the EGD instead of 43239.

    Paperwork Must Back Up 91035 Claim

    For 91035 claims, most payers are serious about their documentation. Check out the documentation requirements for reporting 91035 from HGSAdministrators (HGSA), the Medicare carrier for Pennsylvania.
     
    Check out these guidelines: According to the HGSA Web site, coders should keep these tips in mind when reporting 91035 to HGSA: 

  •  "Documentation supporting the medical necessity of the procedure, including the requirements listed under the 'Indications and Limitations of Coverage'  section of this policy, must be maintained in the medical record."
     
  •  "Documentation must be maintained in the medical record to support that the patient presents diagnostic problems associated with atypical symptoms or the patient's symptoms are suggestive of reflux, but conventional tests have not confirmed the presence of reflux."
     
  •  "Documentation must be available to Medicare upon request (e.g., physician interpretation and report)."

    Reflux/Manometry Coding Is a Combo of New, Old

    Gastroenterologists will occasionally perform a reflux test in the same session as an esophageal manometry. When your gastro performs these procedures in tandem, you should:
     

  •  report 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation) for the reflux test
     
  •  report 91010 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study) for the manometry.

    Who needs it? Patients with esophageal spasms or some other muscle disorder are candidates for a manometry/reflux test combo, says Cheryl Pistone, director of clinical services at Consultants in Gastroenterology in Independence, Mo.

    You May Need Modifier -26

    If your office does not own the equipment you use for the manometry, you must attach modifier -26 (Professional component) to 91010 to show the payer that you  are only coding for the gastro's professional work, not for the equipment.

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