Saturday, April 9, 2011

Information about capsule Endoscopy

General Information about Capsule Endoscopy

Documentations Requirements
Documentation supporting the medical necessity must be made available to Medicare upon request.

1. It is not sufficient merely to link the procedure to a payable ICD-9-CM diagnosis code. The diagnosis or clinical suspicion must be supported and documented with the medical record for the procedure to be paid.

2. Photographic copies of the video images, with the beneficiary's name and the date of service included in the picture must be available for review.

3. The medical records must document the need for this test, and contain reports of previous
endoscopies, and/or diagnostic radiological procedures performed prior to this capsule endoscopy but
during the same current episode of illness.

4. The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss in beneficiaries who had the capsule imaging performed for gastrointestinal bleeding.

5. The medical record must document that a beneficiary who had the capsule imaging performed for
Crohn's disease, had a suspected diagnosis of the disease that needed to be confirmed, or if the
diagnosis was known, it was necessary to determine involvement of the small bowel.


Utilization Guidelines

1. Claims submitted for more than one service per episode of illness will be denied as not medically necessary.
2. Claims for additional tests will be denied as not medically necessary in the absence of supportive

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