Sunday, February 13, 2011

CPT code 91110, 91111 with allowable DX

Payment Guidelines:

Applicable CPT Codes


CPT Code
Description
91110
Gastrointestinal tract imaging, intraluminal (eg. capsule endoscopy), esophagus through ileum, with physician interpretation and report.
91111
Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with physician interpretation and report



Indications

For 91110 (Esophagus through ileum):
For the diagnosis of obscure gastrointestinal bleeding, which may be manifested by iron deficiency anemia, the site of which has not previously been identified by upper gastrointestinal endoscopy, colonoscopy, push enteroscopy or radiological procedure. It may be especially helpful in the diagnosis of angioectasias of the gastrointestinal tract.

As a primary procedure in the evaluation of:

those cases in which the diagnosis of Crohn’s disease is suspected but not diagnosed; or in whom a diagnosis of Crohn’s disease of the colon is known but it is necessary to determine whether there is involvement of the small bowel as well.

suspected small intestinal tumors.

suspected or refractory malabsorptive syndromes (e.g., Celiac disease).
For 91111 (Esophagus): 

This test may be used in the evaluation of esophageal varices when upper gastrointestinal endoscopy is contraindicated. Limitations

When done for gastrointestinal blood loss:

Wireless capsule imaging is payable only for those beneficiaries with documented continuing gastrointestinal blood loss and anemia secondary to bleeding.

This test is only payable for patients, when not contraindicated, who have undergone upper gastrointestinal endoscopy and colonoscopy, within the same episode of illness, that have failed to reveal a source of bleeding.

It is expected that this test will be performed only once during any episode of illness.

The test is payable only for services using FDA approved devices.

This test is covered when performed by physicians with demonstrated competence in evaluating the results.

This test is not payable for patients with hematemesis.

This test is not reimbursable for the confirmation of lesions or pathology discovered by prior endoscopy (including push enteroscopy), colonoscopy, or radiology normally within the reach of upper or lower endoscopes (lesions proximal to the second portion of the duodenum or distal to the ileum).

This test is not reimbursable for colorectal cancer screening.

PATENCY CAPSULE TESTING: The Agile Patency System or similar devices are considered investigational, and thus, not covered.

New code for wireless motility capsule; revised codes for capsule endoscopy

Code 91112 was added for wireless capsule motility. Code 91112 replaces code 0242T, Gastrointestinal tract transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report. New parentheticals have been added to 91111 to direct users to code 91112 for gastrointestinal tract transit and pressure measurements taken from the stomach to the colon via wireless capsule. A parenthetical cross-reference in place of deleted code 0242T alerts users to the appropriate code to report for this procedure.

** 91110 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with physician interpretation and report (Visualization of the colon is not reported separately) (Append modifier 52 if the ileum is not visualized)


**91111 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with physician interpretation and report

(Do not report 91111 in conjunction with 91110) (For measurement of gastrointestinal tract transit times or pressure using wireless capsule, use 91112)

** 91112 Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report
(Do not report 91112 in conjunction with 83986, 91020, 91022, 91117)


** Medicare does not have a National Coverage Determination (NCD) for Wireless Capsule Endoscopy

** Local Coverage Determinations (LCDs) exist and compliance with these policies is required where applicable. For state-specific LCDs, see the LCD Availability Grid (Attachment A).

** For states with no LCDs, see the MCG™ Care Guidelines, 20th edition, 2016, Capsule Endoscopy ACG: A-0134 (AC) for information regarding medical necessity review. 


DESCRIPTION

Wireless capsule endoscopy (WCE), or capsule endoscopy (CPT Codes 91110 & 91111), is a noninvasive procedure, where an ingestible capsule containing a miniaturized video camera is swallowed, that contains a light, transmitter, and batteries. A video recording is taken as it moves through the gastrointestinal (GI) tract. Capsule endoscopy directly studies the entire bowel and is used for detecting lesions or pathology outside the reach of upper or lower endoscopy. Advocates currently support its use to view the entire gastrointestinal tract, esophagus to colon, for multiple conditions. Capsule endoscopy could ultimately reduce the number of initial diagnostic procedures necessary in patients with suspected small bowel disease or chronic GI bleeding. An example includes, but may not be limited to:



POLICY

WCE & Wireless Gastrointestinal Motility Monitoring System (91110, 91111, 91112) require prior authorization for HMO, Individual Marketplace, Elite, and Advantage.

WCE & Wireless Gastrointestinal Motility Monitoring System (91110, 91111, 91112) do not require prior authorization for PPO.

Procedure code 0355T is non-covered.

HMO, PPO, Individual Marketplace, Elite, Advantage Paramount utilizes InterQual® criteria sets for medical necessity determinations for WCE & Wireless Gastrointestinal Motility Monitoring System (91110, 91111, 91112). 

Procedure code 0355T is non-covered 


CODING INFORMATION:

ICD-10 Codes that apply to this policy: Procedure 91110 only covered for the following diagnoses when criteria listed above are met.

C17.0 - C17.9 Malignant neoplasm of small intestine

D37.1 - D37.5 Neoplasm of uncertain behavior of digestive organs

D50.0 Iron deficiency anemia secondary to blood loss (chronic)

D50.9 Iron deficiency anemia, unspecified

D64.9 Anemia, unspecified

E34.0 Carcinoid syndrome


K31.811 Angiodysplasia of stomach and duodenum with bleeding




ICD-10 CODE DESCRIPTION

C17.0 - C17.9 - Opens in a new window Malignant neoplasm of duodenum - Malignant neoplasm of small intestine, unspecified
C78.4 Secondary malignant neoplasm of small intestine
D01.40 - D01.49 - Opens in a new window Carcinoma in situ of unspecified part of intestine - Carcinoma in situ of other parts of intestine
D12.0 - D12.6 - Opens in a new window Benign neoplasm of cecum - Benign neoplasm of colon, unspecified
D13.2 - D13.39 - Opens in a new window Benign neoplasm of duodenum - Benign neoplasm of other parts of small intestine
D37.1 - D37.5 - Opens in a new window Neoplasm of uncertain behavior of stomach - Neoplasm of uncertain behavior of rectum
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D50.9 Iron deficiency anemia, unspecified
D62 Acute posthemorrhagic anemia
E34.0 Carcinoid syndrome
K50.00 - K50.011 - Opens in a new window Crohn's disease of small intestine without complications - Crohn's disease of small intestine with rectal bleeding
K50.013 - K50.019 - Opens in a new window Crohn's disease of small intestine with fistula - Crohn's disease of small intestine with unspecified complications
K50.80 - K50.811 - Opens in a new window Crohn's disease of both small and large intestine without complications - Crohn's disease of both small and large intestine with rectal bleeding
K50.813 - K50.911 - Opens in a new window Crohn's disease of both small and large intestine with fistula - Crohn's disease, unspecified, with rectal bleeding
K50.913 - K50.919 - Opens in a new window Crohn's disease, unspecified, with fistula - Crohn's disease, unspecified, with unspecified complications
K52.0 - K52.1 - Opens in a new window Gastroenteritis and colitis due to radiation - Toxic gastroenteritis and colitis
K52.81 - K55.9 - Opens in a new window Eosinophilic gastritis or gastroenteritis - Vascular disorder of intestine, unspecified
K57.11 Diverticulosis of small intestine without perforation or abscess with bleeding
K57.13 Diverticulitis of small intestine without perforation or abscess with bleeding
K57.51 Diverticulosis of both small and large intestine without perforation or abscess with bleeding
K57.53 Diverticulitis of both small and large intestine without perforation or abscess with bleeding
K63.5 - K63.81 - Opens in a new window Polyp of colon - Dieulafoy lesion of intestine
K90.0 - K90.1 - Opens in a new window Celiac disease - Tropical sprue
K90.89 - K90.9 - Opens in a new window Other intestinal malabsorption - Intestinal malabsorption, unspecified
K92.1 - K92.2 - Opens in a new window Melena - Gastrointestinal hemorrhage, unspecified
R19.5 Other fecal abnormalities
Z85.068 Personal history of other malignant neoplasm of small intestine


Applicable ICD-9 Codes for Endoscopy by Capsule of the Small Intestine - CPT 91110

ICD-9 Code
Description
152.0
Malignant neoplasm of duodenum
152.1
Malignant neoplasm of jejunum
152.2
Malignant neoplasm of ileum
152.3
Malignant neoplasm of Meckel's diverticulum
152.8
Malignant neoplasm of other specified sites of small intestine
152.9
Malignant neoplasm of small intestine, unspecified site
197.4
Secondary malignant neoplasm of small intestine including duodenum
211.2
Benign neoplasm of duodenum, jejunum, and ileum
211.3
Benign neoplasm of colon
230.7
Carcinoma in situ of other and unspecified parts of intestine
235.2
Neoplasm of uncertain behavior of stomach, intestines, and rectum
280.0
Iron deficiency anemia secondary to blood loss (chronic)
457.1
Other noninfectious lymphedema
555.0
Regional enteritis of small intestine
555.1
Regional enteritis of large intestine
555.2
Regional enteritis of small intestine with large intestine
555.9
Regional enteritis of unspecified site
558.9
Other and unspecified noninfectious gastroenteritis and colitis
560.9
Unspecified intestinal obstruction
562.02
Diverticulosis of small intestine with hemorrhage
562.03
Diverticulitis of small intestine with hemorrhage
564.1
Irritable bowel syndrome
569.82
Ulceration of intestine
569.84
Angiodysplasia of intestine (without mention of hemorrhage)
569.85
Angiodysplasia of intestine with hemorrhage
569.86
Dieulafoy lesion (hemorrhagic) of intestine
578.0
Hematemesis
578.1
Blood in stool
578.9
Unspecified, hemorrhage of gastrointestinal tract
579.8
Other specified intestinal malabsorption
759.6
Other congenital hamartoses, not elsewhere classified
787.91
Diarrhea
789.01
Abdominal pain, right upper quadrant
789.02
Abdominal pain, left upper quadrant
789.03
Abdominal pain, right lower quadrant
789.04
Abdominal pain, left lower quadrant
789.05
Abdominal pain, periumbilic
789.06
Abdominal pain, epigastric
789.07
Abdominal pain, generalized
789.09
Abdominal pain, other specified site
792.1
Nonspecific abnormal finding in stool contents
793.4
Nonspecific abnormal findings on radiological and other examination of gastrointestinal tract
V45.89
Other postprocedural status

2 comments:

  1. Hello can we bill a 91110 with a 26 mod if it is a read only??? Per Scott and White we are not allowed to use Mod 26???

    ReplyDelete
  2. This in many cases is the place in-house billing misses the mark, contingent upon the measure of staff that is a piece of the office, assert accommodation and installment posting turn into the needs. Chronic Care Management Software

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