Local Coverage Article Billing and Coding

Billing and Coding: Colon Capsule Endoscopy (CCE)

A58321

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A58321
Article Title
Billing and Coding: Colon Capsule Endoscopy (CCE)
Article Type
Billing and Coding
Original Effective Date
04/12/2021
Revision Effective Date
01/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2022 American Dental Association. All rights reserved.

Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

42 CFR §410.32(d)(3) Claims review

42 CFR §414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Colon Capsule Endoscopy (CCE) L38755.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the related LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

For the purposes of this Article, ICD-10-CM code Z53.8 indicates that the instrument colonoscopy has been attempted and was incomplete and Z53.09 indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.

Documentation Requirements

    1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
    2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
    3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Group 1 Codes
CodeDescription
91113 GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), COLON, WITH INTERPRETATION AND REPORT

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(6 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS code: 91113

Group 1 Codes
CodeDescription
K63.5* Polyp of colon
K92.1* Melena
K92.2* Gastrointestinal hemorrhage, unspecified
R19.5* Other fecal abnormalities
Z53.09* Procedure and treatment not carried out because of other contraindication
Z53.8* Procedure and treatment not carried out for other reasons
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Z53.09 or Z53.8 must be reported with either K63.5, K92.1, K92.2 or R19.5

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All those not listed under the ICD-10-CM Codes that Support Medical Necessity section of this article.

Group 1 Codes

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2022 R1

Under CPT/HCPCS Codes Group 1: Codes deleted 0355T and added 91113. Under ICD-10-CM Codes that Support Medical Necessity Group 1: Paragraph revised the last sentence to read “The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS code: 91113.” This revision is due to the 2022 Annual CPT/HCPCS Code Update and is effective on January 1, 2022.

Associated Documents

Related Local Coverage Documents
LCDs
L38755 - Colon Capsule Endoscopy (CCE)
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
12/21/2021 01/01/2022 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Colon Capsule Endoscopy
  • CCE