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Gastroenterology Coding Alert

Reader Question:

Append Appropriate Modifiers For Incomplete Capsule Endoscopy

Published on Tue Jul 17, 2012

Question: Our gastroenterologist recently performed capsule endoscopy but the capsule did not leave the stomach. So he is planning to repeat the procedure by placing the capsule directly in the duodenum endoscopically for the second procedure. How do we report both these procedures?Nebraska SubscriberAnswer: When your gastroenterologist uses capsule endoscopy to view the gastrointestinal tract from the esophagus to the ileum, you will need to report the procedure using 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report). However, if the procedure had to be discontinued as the capsule got stuck in the food in the stomach, you will need to use the modifier 53 (Discontinued procedure) to 91110 to indicate that your gastroenterologist was not able to view the entire gastrointestinal tract till the ileum.If your gastroenterologist repeats the procedure by placing the capsule endoscopically in the duodenum for the repeat procedure, [...]
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