Hot Coding Topics / modifier 26

GI Tract Reporting: When and When Not To Use 91110, 91111

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...

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February 16, 2011
2011 Medicare Physician Fee Schedule / CPT 2011 / CPT and RBRVS Annual Symposium / Hot Coding Topics

Peds Win Per Component Vaccine Admin Codes, Lose Requested PE RVUs

Pediatricians who were thrilled with CPT 2011’s move to paying vaccines per component got a setback from Medicare’s rejection of the recommended RVUs for new vaccine administration codes 90460 and 90461.

The Relative Update Committe recommended that the 2011 Medicare Physician Fee Schedule and Resource Based Relative Value Scale assign 0.20 practice expense (PE) RVUs to 90460 and 0.16 PE RVUs to 90461. But CMS disagreed with the proposal. “We disagree with the recommendations and will maintain 0.17 RVUs for code 90460 and 0.15 RVUs for code 90461 since these codes would be billed on a per toxoid basis,” said Kenneth Simon, MD, MBA, Senior Medical Officer, Center for Medicare and AMA CPT Editorial Panel Member, in “Medicare Physician Payment Schedule 2011 Changes and Beyond” at the CPT® and RBRVS 2011 Annual Symposium on Nov. 10, 2010.

The increased PEs represent an increase in RVUs from the 2010 values for comparable codes 90465/90467 and 90466/90468. The RUC requested the increase in value due to increased time for patient education. Since the new codes are valued per component, CMS felt no increase was warranted.

CMS assigned RVUs to 90460 and 90461 by crosswalking them with the values of the noncounseling vaccine administration codes 90471 and 90472. This means that new code 90460 has the same RVUs as 90471, and each unit of 90461 has the same RVUs as 90472.

The work and total RVUs for the codes include:

<td width="203"
Code PE  RVU  RUC Proposed PE  RVU MPFS Accepted Total RVUs
90460 0.20 0.17 0.59
90461 0.16 0.15 0.3
90465

...

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November 29, 2010
Coding Challenge / CPT 2010 / Medicare

AMA Symposium Report: Low-Level Consult Reporting in 2010

Hey, Coding News readers! It’s your turn to weigh in on the consult controversy. Question: What should you do for Medicare 2010 coding if an inpatient consult on a patient’s initial hospital day does not support 99221? Answer: Kenneth Simon, MD, MBA, FACS, CMS, senior medical officer at the CPT symposium was very adamant that you [...] Related articles:

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November 18, 2009
CMS / CPT / Medicare / Provider News

CMS at AMA Chicago: We’re Reducing Consult Request Requirement

CMS auditors will look for 1 less thing in consult documentation. With Medicare’s invalidation of consultation codes 99241-99255 in 2010, your ICD-9 codes better prove why two MDs are necessary on the same patient’s hospital care or the physician better specify why in his note. Separate ICD-9 codes will help substantiate the medical necessity for providing consultative [...] Related articles:

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November 13, 2009
CMS / CPT / Medicare / Provider News

Medicare Changes to 2010 CPT Inpatient Consultation Codes

Prevent 99251-99245 denials in 2010 with this checklist. Multiple physicians using the same hospital codes sounds like a recipe for denials, but that’s what Medicare is instructing physician inpatient consultants and care coordinators to do. Whether carriers will kick out these submissions as coordination of care or inpatient admit limiting admit edits is contractor specific, Charles [...] Related articles:

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November 13, 2009