SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Endoscopy by Capsule

A56461

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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General Information

Source Article ID
N/A
Article ID
A56461
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Endoscopy by Capsule
Article Type
Billing and Coding
Original Effective Date
10/01/2017
Revision Effective Date
11/16/2023
Revision Ending Date
03/06/2024
Retirement Date
N/A

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CMS National Coverage Policy

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Article Guidance

Article Text

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.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(117 Codes)
Group 1 Paragraph

ICD-10-CM codes for the small bowel capsule (CPT code 91110)

ICD-10-CM code Z98.890 or Z98.891 for purposes of this LCD indicates that a medically necessary upper endoscopy and colonoscopy related to the current episode of care were carried out before endoscopy by capsule was done. If the patient has had prior total colectomy, this ICD-10-CM code should still be used to signify the upper endoscopy was performed. Therefore, ICD-10-CM code Z98.890 or Z98.891 must be reported on all claims for endoscopy by capsule of the small bowel EXCEPT when performed in patients with documented intussusception (ICD-10-CM code K56.1) in order for coverage to occur. To support medical necessity for endoscopy by capsule of the small bowel, ICD-10-CM code Z98.890 or Z98.891 plus one (or more) of the ICD-10-CM codes listed below must be reported.

ICD-10-CM codes D12.0-D12.5 should be reported for patients with polyposis syndrome that may have small bowel neoplasia.

Group 1 Codes
Code Description
C17.0 - C17.3 Malignant neoplasm of duodenum - Meckel's diverticulum, malignant
C17.8 Malignant neoplasm of overlapping sites of small intestine
C17.9 Malignant neoplasm of small intestine, unspecified
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.019 Malignant carcinoid tumor of the small intestine, unspecified portion
C78.4 Secondary malignant neoplasm of small intestine
D01.40 Carcinoma in situ of unspecified part of intestine
D01.49 Carcinoma in situ of other parts of intestine
D12.0 - D12.5 Benign neoplasm of cecum - Benign neoplasm of sigmoid colon
D13.2 Benign neoplasm of duodenum
D13.39 Benign neoplasm of other parts of small intestine
D3A.010 Benign carcinoid tumor of the duodenum
D3A.011 Benign carcinoid tumor of the jejunum
D3A.012 Benign carcinoid tumor of the ileum
D3A.019 Benign carcinoid tumor of the small intestine, unspecified portion
D37.1 - D37.5 Neoplasm of uncertain behavior of stomach - Neoplasm of uncertain behavior of rectum
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
I85.00 Esophageal varices without bleeding
I85.10 Secondary esophageal varices without bleeding
I89.0 Lymphedema, not elsewhere classified
K50.00 Crohn's disease of small intestine without complications
K50.011 - K50.014 Crohn's disease of small intestine with rectal bleeding - Crohn's disease of small intestine with abscess
K50.018 Crohn's disease of small intestine with other complication
K50.10 Crohn's disease of large intestine without complications
K50.111 - K50.114 Crohn's disease of large intestine with rectal bleeding - Crohn's disease of large intestine with abscess
K50.118 Crohn's disease of large intestine with other complication
K50.80 Crohn's disease of both small and large intestine without complications
K50.811 - K50.814 Crohn's disease of both small and large intestine with rectal bleeding - Crohn's disease of both small and large intestine with abscess
K50.818 Crohn's disease of both small and large intestine with other complication
K50.90 Crohn's disease, unspecified, without complications
K50.911 - K50.914 Crohn's disease, unspecified, with rectal bleeding - Crohn's disease, unspecified, with abscess
K50.918 Crohn's disease, unspecified, with other complication
K52.21 Food protein-induced enterocolitis syndrome
K52.22 Food protein-induced enteropathy
K52.29 Other allergic and dietetic gastroenteritis and colitis
K52.3 Indeterminate colitis
K52.81 Eosinophilic gastritis or gastroenteritis
K52.82 Eosinophilic colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
K55.20 Angiodysplasia of colon without hemorrhage
K55.21 Angiodysplasia of colon with hemorrhage
K56.1 Intussusception
K56.600 Partial intestinal obstruction, unspecified as to cause
K56.601 Complete intestinal obstruction, unspecified as to cause
K56.609 Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction
K57.01 Diverticulitis of small intestine with perforation and abscess with bleeding
K57.11 Diverticulosis of small intestine without perforation or abscess with bleeding
K57.13 Diverticulitis of small intestine without perforation or abscess with bleeding
K57.41 Diverticulitis of both small and large intestine with perforation and abscess with bleeding
K57.51 Diverticulosis of both small and large intestine without perforation or abscess with bleeding
K57.53 Diverticulitis of both small and large intestine without perforation or abscess with bleeding
K58.0 Irritable bowel syndrome with diarrhea
K58.9 Irritable bowel syndrome without diarrhea
K63.3 Ulcer of intestine
K63.5 Polyp of colon
K63.81 Dieulafoy lesion of intestine
K70.2 Alcoholic fibrosis and sclerosis of liver
K70.30 Alcoholic cirrhosis of liver without ascites
K70.31 Alcoholic cirrhosis of liver with ascites
K74.01 Hepatic fibrosis, early fibrosis
K74.02 Hepatic fibrosis, advanced fibrosis
K74.3 Primary biliary cirrhosis
K74.4 Secondary biliary cirrhosis
K74.60 Unspecified cirrhosis of liver
K74.69 Other cirrhosis of liver
K76.6 Portal hypertension
K90.41 Non-celiac gluten sensitivity
K90.49 Malabsorption due to intolerance, not elsewhere classified
K90.89 Other intestinal malabsorption
K92.0 Hematemesis
K92.1 Melena
K92.2 Gastrointestinal hemorrhage, unspecified
Q85.81 PTEN hamartoma tumor syndrome
Q85.82 Other Cowden syndrome
Q85.83 Von Hippel-Lindau syndrome
Q85.89 Other phakomatoses, not elsewhere classified
Q85.9 Phakomatosis, unspecified
R10.11 - R10.13 Right upper quadrant pain - Epigastric pain
R10.2 Pelvic and perineal pain
R10.31 - R10.33 Right lower quadrant pain - Periumbilical pain
R10.84 Generalized abdominal pain
R19.5 Other fecal abnormalities
R19.7 Diarrhea, unspecified
R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
Z98.890 Other specified postprocedural states
Z98.891 History of uterine scar from previous surgery

Group 2

(12 Codes)
Group 2 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

ICD-10-CM codes for the esophageal capsule (CPT code 91111)

Group 2 Codes
Code Description
I85.00 Esophageal varices without bleeding
I85.10 Secondary esophageal varices without bleeding
K70.2 Alcoholic fibrosis and sclerosis of liver
K70.30 Alcoholic cirrhosis of liver without ascites
K70.31 Alcoholic cirrhosis of liver with ascites
K74.01 Hepatic fibrosis, early fibrosis
K74.02 Hepatic fibrosis, advanced fibrosis
K74.3 Primary biliary cirrhosis
K74.4 Secondary biliary cirrhosis
K74.60 Unspecified cirrhosis of liver
K74.69 Other cirrhosis of liver
K76.6 Portal hypertension
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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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.

Code Description

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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.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.


Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/16/2023 R10

R10

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

03/09/2023 R9

R9
Revision Effective: 03/09/2023
Revision Explanation: Annual review, no changes 

10/01/2022 R8

R8
Revision Effective: 10/01/2022
Revision Explanation: Annual ICD-10 update, Q85.8 was deleted and added Q85.81, Q85.82, Q85.83 and Q85.89  

03/17/2022 R7

R7
Revision Effective: 03/10/2022
Revision Explanation:  Updated article text to include information for how to bill to Part A MAC, that the physcian services use same POS as technical component was received by the patient , and combined the lists for appropriate POS for 9110 and 91111 for Part B MACs.

03/03/2022 R6

R6
Revision Effective: 03/03/2022
Revision Explanation: Annual review, no changes were made.

03/04/2021 R5

R5
Revision Effective: 03/04/2021
Revision Explanation: Annual review, no changes were made.

10/01/2020 R4

R4
Revision Effective: 10/01/2020
Revision Explanation: During annual ICD-10 update K74.0 was deleted and replaced with K74.01 and K74.02 in group 1 and group 2. And corrected typo I paragraph one for ICD-10 codes Z89981 should have have been Z98.891 after Therefore, ICD-10 CM code.

03/26/2020 R3

R3

Revision Effective: 03/26/2020

Revision Explanation: Corrected typo in group one paragraph under ICD-10 codes that support medical necessity.

10/31/2019 R2

R2

Revision Effective: n/a

Revision Explanation: Annual Review, no changes

10/31/2019 R1

R1

Revision Effective: 10/31/2019

Revision Explanation: Added information on billing Part A and Part B claims for endoscopy by capsule in article text under documentation requirements.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L34081 - Endoscopy by Capsule
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