LCD Reference Article Billing and Coding Article

Billing and Coding: Wireless Capsule Endoscopy

A57753

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Draft Article
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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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57753
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Wireless Capsule Endoscopy
Article Type
Billing and Coding
Original Effective Date
11/21/2019
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 2023 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 © 2023 American Dental Association. All rights reserved.

Copyright © 2024, 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

N/A

Article Guidance

Article Text

Refer to Local Coverage Determination (LCD) L35089, Wireless Capsule Endoscopy, for reasonable and necessary requirements.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
083x Ambulatory Surgery Center
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
036X Operating Room Services - General Classification
040X Other Imaging Services - General Classification
045X Emergency Room - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
0750 Gastro-Intestinal (GI) Services - General Classification
076X Specialty Services - General Classification
096X Professional Fees - General Classification
0972 Professional Fees - Radiology - Diagnostic
0973 Professional Fees - Radiology - Therapeutic
0982 Professional Fees - Outpatient Services
0988 Professional Fees - Consultation
N/A

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

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

Group 1 Codes
Code Description
91110 Gi trc img intral esoph-ile
91111 Gi trc img intral esophagus
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(51 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.

Medicare is establishing the following limited coverage for CPT/HCPCS code: 91110

Group 1 Codes
Code Description
A18.32* Tuberculous enteritis
A18.39* Retroperitoneal tuberculosis
A18.83 Tuberculosis of digestive tract organs, not elsewhere classified
C17.0 Malignant neoplasm of duodenum
C17.1 Malignant neoplasm of jejunum
C17.2 Malignant neoplasm of ileum
C17.3 Meckel's diverticulum, malignant
C17.8 Malignant neoplasm of overlapping sites of small intestine
C17.9 Malignant neoplasm of small intestine, unspecified
C49.A3 Gastrointestinal stromal tumor of small intestine
C49.A4 Gastrointestinal stromal tumor of large intestine
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
D13.2 Benign neoplasm of duodenum
D13.30 Benign neoplasm of unspecified part of small intestine
D13.39 Benign neoplasm of other parts of small intestine
D37.2 Neoplasm of uncertain behavior of small intestine
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D50.9* Iron deficiency anemia, unspecified
E16.4* Increased secretion of gastrin
I77.6 Arteritis, unspecified
K31.811 Angiodysplasia of stomach and duodenum with bleeding
K31.82 Dieulafoy lesion (hemorrhagic) of stomach and duodenum
K50.00 Crohn's disease of small intestine without complications
K50.011 Crohn's disease of small intestine with rectal bleeding
K50.018 Crohn's disease of small intestine with other complication
K50.019 Crohn's disease of small intestine with unspecified complications
K50.10 Crohn's disease of large intestine without complications
K50.111 Crohn's disease of large intestine with rectal bleeding
K50.118 Crohn's disease of large intestine with other complication
K50.119 Crohn's disease of large intestine with unspecified complications
K50.80 Crohn's disease of both small and large intestine without complications
K50.811 Crohn's disease of both small and large intestine with rectal bleeding
K50.818 Crohn's disease of both small and large intestine with other complication
K50.819 Crohn's disease of both small and large intestine with unspecified complications
K50.90 Crohn's disease, unspecified, without complications
K50.911 Crohn's disease, unspecified, with rectal bleeding
K50.918 Crohn's disease, unspecified, with other complication
K50.919 Crohn's disease, unspecified, with unspecified complications
K52.0 Gastroenteritis and colitis due to radiation
K55.1 Chronic vascular disorders of intestine
K55.21 Angiodysplasia of colon with hemorrhage
K57.11 Diverticulosis of small intestine without perforation or abscess with bleeding
K57.13 Diverticulitis of small intestine without perforation or abscess with bleeding
K57.51 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
K63.81 Dieulafoy lesion of intestine
K90.0 Celiac disease
K92.1 Melena
R19.5 Other fecal abnormalities
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: Use A18.32 or A18.39 for tuberculosis of small intestine or tuberculous enteritis.
*Note: Use E16.4 for Zollinger-Ellison syndrome.
*Note: Use D50.9 when anemia continues to be unexplained after upper and lower endoscopy.

Group 2

(1 Code)
Group 2 Paragraph

Medicare is establishing the following limited coverage dual diagnosis requirement for CPT/HCPCS code: 91111

Covered for primary ICD-10-CM code:

Group 2 Codes
Code Description
K76.6 Portal hypertension

Group 3

(2 Codes)
Group 3 Paragraph

Covered for secondary ICD-10-CM codes:

Group 3 Codes
Code Description
I85.10 Secondary esophageal varices without bleeding
I85.11 Secondary esophageal varices with bleeding
N/A

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

Group 1

Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this policy.

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
083x Ambulatory Surgery Center
085x Critical Access Hospital
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.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, for further guidance.


Code Description
036X Operating Room Services - General Classification
040X Other Imaging Services - General Classification
045X Emergency Room - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
0750 Gastro-Intestinal (GI) Services - General Classification
076X Specialty Services - General Classification
096X Professional Fees - General Classification
0972 Professional Fees - Radiology - Diagnostic
0973 Professional Fees - Radiology - Therapeutic
0982 Professional Fees - Outpatient Services
0988 Professional Fees - Consultation
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2022 R1

Article revised and published on 1/20/2022 effective for dates of service on and after 01/01/2022 to reflect the annual HCPCS/CPT code Updates. For the following CPT codes either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays: 91110 and 91111.

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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
L35089 - Wireless Capsule Endoscopy
Related National Coverage Documents
NCDs
100.2 - Endoscopy
SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/14/2022 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

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