Wiki Endoscopic Placement/Advancement of Capsules

[SamanthaLunde]

Hello, I am interested to hear how other coders are addressing this sticky area. We own the capsules, so when swallowed in office we bill global. However, in some instances our physicians have elected to place them endoscopically. So we have billed 43235 - 52(if the scope is not advanced to the duodenum) in the instance that a patient would be unable to obtain adequate deglutition due to dysphagia, with 91110-52 on the date of interpretation due to the fact that the esophagus is not captured on capsule images.

Currently, we have a case where the patient suffers from crohn's disease which requires staging, but also has gastroparesis. Due to concern of the capsule not advancing they want to go in and advance it manually after the capsule is swallowed. I believe we could bill 43235 on date of EGD and 91110 (if capsule reaches the ileum) on date of interpretation. I see no CCI edit that would prevent it, but I have never tried to bill a capsule and an EGD same day.

Does this seem correct? Please share any insight or red flags you see. Thank you so much!

 

[DFUGET]

You should not be billing 43235/52 if they do not reach the duodenum. You should bill 43200. Endoscopic placement of the capsule is not separately payable unless done for diagnostic or therapeutic purposes.

 

[clarkmegan]

Hello, I am interested to hear how other coders are addressing this sticky area. We own the capsules, so when swallowed in office we bill global. However, in some instances our physicians have elected to place them endoscopically. So we have billed 43235 - 52(if the scope is not advanced to the duodenum) in the instance that a patient would be unable to obtain adequate deglutition due to dysphagia, with 91110-52 on the date of interpretation due to the fact that the esophagus is not captured on capsule images.

Currently, we have a case where the patient suffers from crohn's disease which requires staging, but also has gastroparesis. Due to concern of the capsule not advancing they want to go in and advance it manually after the capsule is swallowed. I believe we could bill 43235 on date of EGD and 91110 (if capsule reaches the ileum) on date of interpretation. I see no CCI edit that would prevent it, but I have never tried to bill a capsule and an EGD same day.

Does this seem correct? Please share any insight or red flags you see. Thank you so much!

According to CMS NCCI, the 2 are not billable unless "the EGD is a medically necessary and complete diagnostic procedure." They also say EGD cannot be billed just to place the M2A. It seems like your scenario may fall under placement of the m2a. Perhaps if the EGD was for dysphagia and gastroparesis and the M2A was for crohns disease, the 2 would be payable? That is just a guess.

There is no CCI edit because they would be billed on 2 separate days in your scenario. Since the M2A and EGD are both types of endoscopies, they probably look at it as billing the same procedure twice.


Here is a link to the NCCI edits to download that specifically discusses this scenario. I have copied an excerpt below. See Chapter 11, page 12. https://www.cms.gov/Medicare/Coding...ndex.html?redirect=/NationalCorrectCodInitEd/

"Similarly the procedures described by CPT codes 91110 (gastrointestinal tract intraluminal imaging, esophagus through ileum) and 91112 (gastrointestinal transit and pressure measurement, stomach through colon) require a patient to swallow a capsule. If the patient cannot swallow a capsule, and a physician places it in the stomach using endoscopic guidance, CPT code 43235 shall not be reported unless the physician performs a medically reasonable and necessary complete diagnostic upper gastrointestinal endoscopy procedure. CPT code 43235 should not be reported with modifier 52 for endoscopic guidance to place the capsule in the stomach."

 

[AIDH2721]

You should not be billing 43235/52 if they do not reach the duodenum. You should bill 43200. Endoscopic placement of the capsule is not separately payable unless done for diagnostic or therapeutic purposes.

help please, question? does this stand for both professional and facility billing? if only doing 43235 (performed to place camera) would it be appropriate to bill for facility only? I bill for both professional and Endoscopy center charges