ASC Facility Billing Question – CPT 91035 (Bravo) with CPT 43239

[AlishaFEC]

We recently started performing Bravo pH studies in our ASC and are seeing a consistent denial pattern from commercial and Medicaid payers.

Claim setup:

• ASC facility billing
• UB-04 for commercial/Medicaid
• Revenue code 0490
• CPT 43239 (EGD with biopsy)
• CPT 91035-TC (Bravo capsule pH monitoring technical component)
• Same DOS as capsule placement
• Professional claim for 91035 mod 26 is billed separately on date of interpretation and is being paid

Current outcome:

• 43239 pays
• 91035-TC denies with CO-97
• No additional remark codes
• Appeals are being upheld as "service included in case rate"
• other ways of refiling w/ mod TC and 59 have the same outcome

What we've already verified:

• CPT pair 43239/91035 has NCCI modifier indicator 9 (no active edit)
• Medicare pays both services
• Professional component of 91035 is being paid
• Denials are occurring across multiple commercial and Medicaid plans

Contract
As an example, for Healthfirst Our ASC agreement reimburses ambulatory surgical procedures at a flat rate of $655 per procedure and references CMS reimbursement policies, including the Multiple Endoscopy Reduction Rule. However, I have not been able to locate any ASC policy stating that 91035 is packaged into 43239.

Questions:

1. Has anyone successfully obtained separate ASC facility reimbursement for 91035 when billed with 43239?
2. Are commercial plans commonly packaging the technical component of 91035 into the ASC case rate?
3. Are you billing 91035 with or without modifier TC on institutional ASC claims?
4. Has anyone identified a CMS, ASC, or payer policy that specifically supports bundling 91035 into the primary EGD procedure?

Any guidance or examples of paid ASC facility claims would be appreciated.