Tuesday, December 28, 2010

CPT 91110 - Guidelines and not covered situations


Treatment/Application Guidelines: 
 
The following criteria must be met for certification of Wireless Capsule Endoscopy. 


A.    Endoscopy by Capsule of the Small Intestine - CPT 91110 

 
I.    Crohn's Disease

 
Endoscopy by capsule is indicated for the diagnosis of Crohn's disease when the condition has not been previously confirmed or when a diagnosis of colitis of an indeterminate type affecting the colon is known, and a more specific diagnosis is sought by evaluating for possible small bowel involvement.
Endoscopy by capsule is reasonable in those patients in whom there is strong clinical suspicion of Crohn's disease (with abdominal pain, weight loss, diarrhea, anorexia, bleeding and biochemical indicators of inflammation) and in whom a prior radiologic study to exclude stricture is performed but does not demonstrate Crohn's disease. Capsule endoscopy may be reasonable without the patient having undergone upper GI endoscopy and colonoscopy.


II.    Gastrointestinal Bleeding 

 
The test is indicated for the diagnosis of occult gastrointestinal bleeding, the site of which has not been identified previously by any of the following: upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures. The test is especially helpful in the diagnosis of angiodysplasias of the gastrointestinal tract.
Endoscopy by capsule is limited to those patients who have generally undergone both upper GI endoscopy and colonoscopy, and when these tests have failed to reveal a source of bleeding. In rare situations where hemotemesis occurs repeatedly and upper GI endoscopy is repeatedly negative, capsule endoscopy may be indicated. 


III.    Small Bowel Neoplasm
The test is indicated for the detection of neoplasms of the small bowel, when the diagnosis has not been previously confirmed by other studies (e.g., upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures). The patient must be symptomatic for a neoplasm (e.g., GI bleeding) or have a documented polyposis syndrome that is associated with small bowel neoplasia or there is other history suggesting the presence of small bowel neoplasia and other diagnostic testing to assess these symptoms (i.e., upper GI endoscopy and/or colonoscopy) must have been performed. 


IV.    Other Conditions
Evaluation of malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy of obscure origin is reasonable when it is suspected to originate in the small intestinal mucosa. Appropriate prior negative or non-diagnostic evaluations of the esophagus, stomach, duodenum/small intestine, and colon by flexible endoscopy, and complementary radiologic procedures and/or microbiologic studies must be documented. 


V.    Evaluation Prior to Surgery
Evaluation of extent of small bowel involvement with arteriovenous malformations or lymphangiectasia for patients who are contemplated for surgical resection of the small bowel to control recurrent bleeding or protein loss is reasonable. 


B.    This test is not covered in the following situations: 

 
o    Colorectal cancer screening.
o    When carried out by FDA non-approved devices.
o    Confirmation of lesions or pathology normally within the reach of upper or lower endoscopy (lesions proximal to the ligament of Treitz or distal to the ileum) or for the confirmation of lesions or pathology discovered by prior endoscopy (including push enteroscopy), colonoscopy, or radiology.
o    Current history of dysphagia suggestive of esophageal stricture.

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