This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34081-Endoscopy by Capsule.
General Guidelines for Claims submitted to Part A or Part B MAC:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.
The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
Documentation Requirements
The patient’s medical record should include but is not limited to:
- The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
- Relevant medical history
- Results of pertinent tests/procedures
- Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
For claims submitted to the Part B MAC:
All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim. The place of service code used by the physician and other suppliers should be the setting in which the beneficiary received the technical component service.
Claims for endoscopy by capsule are payable under Medicare Part B in the following places of service:
CPT code 91110 and 9111, global is payable in office (11), IDTF (49) and independent clinic (49)
CPT code 91110-TC and 91111-TC is payable in office (11), IDTF (49), independent clinic (49), federally qualified health center (50) and rural health clinic (72).
CPT code 91110-26 (interpretation)and 9111-26 is payable in office (11), outpatient hospital (19), inpatient hospital (21), outpatient hospital (22), independent clinic (49) and public health clinic (71).
For claims submitted to the Part A MAC:
Submit bill type codes for claims for endoscopy by capsule payable under Medicare Part A and revenue code if applicable (see Bill Type Codes and Revenue Codes below).
To report Patency Capsule Testing for denial purposes, use CPT code 91299, and enter "Patency Capsule Testing" in Item 19 of the CMS-1500 claim form or the electronic equivalent.
The ingestion of the capsule is part of the test and an evaluation & management (E&M) service may not be billed for this purpose.
Telemetric Gastrointestinal Capsule Imaging consists of a technical portion of the service (provision of the capsule, hookup of the recording equipment, and downloading of the digital data to the computer with processing and creation of video images) and a professional component (review of the images and interpretation with report). The place of service for the technical component of the test should be reported as the location where the download of the images to the computer is performed.
For claims submitted to the Part A MAC:
Hospital Inpatient Claims:
- The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
- The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
- For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Hospital Outpatient Claims:
- The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).
- The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
