This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33774 Wireless Capsule Endoscopy provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Refer to the LCD for reasonable and necessary requirements and limitations.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.
Coding Guidelines
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
The date of service should be entered as the date of ingestion of the capsule and the date hook-up of the data recorder device was performed regardless of the number of days the recorder is worn.
Wireless capsule endoscopy of the small bowel should be coded with the CPT code 91110.
Wireless capsule endoscopy of the esophagus through the ileum should be coded with CPT code 91110. (If the ileum is not visualized add Modifier 52)
Wireless capsule endoscopy of the esophagus should be coded with CPT code 91111. A dual diagnosis is required when billing this service.
CPT codes 91110 and 91111 consist of a professional and technical component.
The technical portion (TC modifier) of the service includes:
- provision of the capsule;
- hook-up of the recording equipment;
- downloading of the digital data with processing and creation of video images.
The professional component (26 modifier) of the service includes review of the images and interpretation with report.
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- 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.
- 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.
- The record must include documentation that attempts were made to identify the source of the bleeding, but the site of bleeding was not previously identified by colonoscopy, or endoscopy.
- The medical record must clearly reflect why the patient was not a candidate for conventional endoscopy. There must be documentation of specific co-morbidities and complicating medical conditions that lead the performing provider of the conventional endoscopy to believe that the risk/benefit ratio of a conventional endoscopy was not maintained. The medical record must also support how the capsule endoscopy would contribute to the patient’s care.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Compliance with the provisions in LCD L33774 Wireless Capsule Endoscopy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
