Bill all three or get a denial: supply, injection, and illumination. Coding for photodynamic therapy (PDT) involves three key components, which means you should look into multiple CPT® codes to describe your claim appropriately. But this could jeopard...
If you mistake modifiers 52 and 53 as one or the other because they’re both used for incomplete procedures, you’ll end up losing your reimbursement. Remember these two have extremely distinctive functions.
Consider a situation when the gastroenterologist performs an esophagogastroduodenoscopy (EGD) to examine the lining of the esophagus, stomach, and upper duodenum of a patient as part of a GERD evaluation.
Suppose that while inserting the endoscope, the patient registers unstable vital signs. The gastroenterologist, then, decides it is not in the patient’s best interest to continue the procedure. You would report this on your claim using:
Other situations that would call for a discontinued procedure include respiratory distress (786.09), hypoxia (799.02), irregular heart rhythm (427.9), and others usually related to the sedation medications.
Modifier 53 Defined: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances, or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.
In addition, you shouldn’t disregard the importance of submitting documentation that shows:
Taking on the same scenario, the gastroenterologist begins the diagnostic EGD but stopped without examining the entire upper gastrointestinal tract because she encounters an obstructing lesion in the middle of the stomach. In this case, you should attach modifier 52 to the CPT, says Margaret Lamb, RHIT, CPC, of Great Falls Clinic...
While you know for sure that you can report 91110 and 91111 for capsule study, but knowing just that is not enough to prevent your claims from being denied. We’ll tell you just when it is appropriate to report them and which modifiers to append.
Reporting a Repeat Procedure with 91110
Sometimes, your gastroenterologist would use a capsule study to image the intraluminal esophagus all the way through the ileum and reaching the colon. In this case, you should report 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report).
Let’s take an example. Patient comes in for a capsule endoscopy, but the capsule gets stuck in foodon hour five and visuals cannot be seen past the stomach. The gastroenterologist ends up repeating the procedure to see if she can see the small and large intestine.
First, you would code 91110 and then attach modifier 53 (Discontinued procedure) to indicate that the physician repeated the procedure. If the physician decides not to repeat the procedure, you should append modifier 52 (Reduced services) to reflect that the capsule imaged the patient’s anatomy until it became lodged in the food.
If you plan on repeating a capsule study due to technical problems, it is a good idea to pre-authorize payment for the second study with the carrier. You may need to provide records of the incomplete study.
CPT 91110’s descriptor clearly states the evaluation is from the esophagus to the ileum. The only time this won’t be true is when the gastroenterologist places the pill cam endoscopically for the study, says Joel V. Brill, MD, AGAF, chief medical officer at Predictive Health LLC in Phoenix. Again in this case, you should attach modifier 52 to 91110.
Know What ‘SB’ and ‘ESO’ Mean on PillCam...
If you’ve been looking for a code on colon motility study and being frustrated for the lack of it, your search is over. CPT 2011 debuts a new code for a manometric study, along with two revised codes for esophageal pH monitoring.
For gastroenterology, you have a lot of changes to sort through — many involving deletions on low use codes or clean-up work.
Here’s How to Use New Manometric Study Codes
You should pay attention on two new codes for a manometric study: 91117 (Colon motility [manometric] study, minimum 6 hours continuous recording [including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed], with interpretation and report), and 91013 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; with stimulation or perfusion during 2-dimensional data study [e.g., stimulant, acid or alkali perfusion] [List separately in addition to code for primary procedure]).
CPT 91117 is just for the study itself, not for the same session with catheter placement. The radiologist may place the catheter in a prior procedure and the gastroenterologist may come in and out to supervise the testing and any provocations that are performed. Thus, you should include the provocations in the study and report 97117 only once no matter how many times the testing is done.
You can use 91013 in cases like assessment of the effect on the measured esophageal motility when the patient’s esophagus is exposed to different stimulant liquids, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA’s CPT Advisory Panel. The code also applies when intravenous medications are administered to try to produce symptoms. CPT 91010 is included in 91013 and would not be billed separately, he adds.
Use 91034, 91035 in a New Way
Aside from debuting...
Question: I’m receiving contradictory guidance on which modifier to use when a gastroenterologist does an incomplete colonoscopy. Should I use modifier 52 or 53? Answer: CPT 2011 ends the days of arguing over whether to use modifier 52 or 53 for ...
This modifier is key to E&M and counseling codes cohabiting on your claim.
Question: Can I report alcohol cessation counseling codes along with E/M codes, or do I have to choose one or the other?
Idaho Subscriber
Answer: You can,...
Don’t be caught asleep: Patient history is one element of proper Dx coding.
Many coders hesitate to report V codes, or simply use them incorrectly, but sometimes this section of ICD-9 most accurately describes the reason for the patient’s condition....
Following 10-year-rule eliminates G0121 rejection.
If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch.
Use this guidance to capture every screening dollar your gastroenterologist deserves.
Home in on Eligibility Requirements for...
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Reading 44373’s code descriptor is key to getting your G Tube claim right. Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the [...] Related articles:
Question: A local family physician refers a patient to our gastroenterologist for a diagnostic colonoscopy. The patient reports to the practice and meets the gastroenterologist for the first time. After answering some patient questions during a brief introduction, the gastroenterologist performs a diagnostic colonoscopy with brushing. The patient had never met the gastroenterologist before. Is the time he spent with the patient [...] Related articles:
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