Getting denials for breath testing? You might not be meeting its coding requirements. It is not easy to file multiple claims each day, especially when handling high volumes of patients and clinical emergencies. A simple coding mistake, such as an inappropriate procedure code, can trigger investigations by insurance companies.
Coding requires attention, but sometimes, people overcomplicate the process with inefficient practices like poor workflows and ignoring payer-specific guidelines. Our advice is to understand one code at a time. Therefore, today, we will discuss the most appropriate code for the hydrogen or methane breath test, CPT code 91065. Let’s get started!
91065 CPT Code – Description
The Current Procedural Terminology (CPT) code 91065 is a popular gastroenterology code. It simply refers to a hydrogen/methane breath test. To be more specific, gastroenterology billing specialists primarily use this CPT code to bill a non-invasive diagnostic test, essential for detecting several gut issues like:
- Small Intestinal Bacterial Overgrowth (SIBO)
- Intestinal Methanogen Overgrowth (IMO)
- Carbohydrate Malabsorption (Lactose Intolerance)
So, what exactly is a hydrogen or methane breath test? It is a simple diagnostic analysis that measures the hydrogen and methane levels in a person’s breath after ingesting a substrate (lactulose or glucose) solution.
During the test, the patient first provides a baseline breath sample before drinking the solution. He then drinks the substrate mixture and provides a breath sample every 15 minutes for up to 2 hours, allowing healthcare providers to detect the presence of bacteria or methanogens in the upper digestive tract.
This examination has some prior requirements. These include avoiding:
- Antibiotics for four weeks,
- Laxatives or fiber supplements for one week and
- Cigarettes or vapes for 24 hours before taking the test.
The patient also has to fast 12 hours before this analysis.
Scenarios Where CPT Code 91065 is Applicable
Don’t want to experience any more denials due to inaccurate coding? Here are some practical scenarios where CPT Code 91065 is applicable:
Lactose Intolerance Confirmation
Let’s suppose a 25-year-old woman visits a gastroenterologist with persistent complaints of bloating, diarrhea, and abdominal pain. The doctor takes her medical history and notes that she typically experiences these symptoms after 30 minutes of consuming dairy products. He orders a diagnostic hydrogen breath analysis.
The patient fasts for 12 hours and returns the next day for the test. After consuming a substrate mixture containing lactose, she provides breath samples at 15-minute intervals for two hours. This examination allows the gastroenterologist to confirm his suspicion that the patient has lactose intolerance. He uses CPT code 91065 to report this diagnostic analysis.
Identifying Small Intestinal Bacterial Overgrowth (SIBO)
A woman takes her 8-year-old child with chronic abdominal pain to a pediatric physician. She reports that the child is experiencing loss of appetite, rapid weight loss, and persistent diarrhea. The doctor suspects bacterial overgrowth and orders a hydrogen breath test.
On the test day, the doctor asks the child to drink a substrate mixture containing specific sugar. After drinking the liquid, the child blows air into a machine at 30-minute intervals. The pediatric physician measures the hydrogen levels in the exhaled breaths and identifies the actual issue: bacterial overgrowth in the small intestine. The billing team uses CPT code 91065 to bill for this test.
Post-Surgical Bacterial Overgrowth Evaluation
Let’s consider another SIBO scenario! A 57-year-old patient develops severe diarrhea after undergoing gastrectomy. Small intestinal bacterial overgrowth (SIBO) is common after this surgery. The doctor orders a hydrogen breath test to confirm the diagnosis.
After the patient consumes the sugar solution, the clinical staff collects nine breath samples over 2 hours at 15-minute intervals. The test results suggest post-surgical SIBO. The doctor uses CPT code 91065 to report this distinct diagnostic test.
Applicable Modifiers for CPT Code 91065
You can usually report CPT code 91065 without any modifiers. However, you might have to apply the following modifiers in specific scenarios:
Modifier 26
Modifier 26 points towards the professional component of the service. In simple terms, apply this modifier to CPT code 91065 when a physician only interprets test results and does not perform the test.
Modifier TC
This two-digit code is the opposite of modifier 26. It refers to the technical component of the test. To be more specific, you can use modifier TC when a physician only performs the hydrogen breath test and does not interpret the results.
Modifier 59
Modifier 59 is quite popular. However, it is also most scrutinized, so use it carefully with CPT code 91065. This modifier clarifies that the performed procedure is distinct and separately identifiable from other services or procedures performed on the same day.
You can apply this modifier to the hydrogen breath test if it is unrelated to other procedures you have performed on the same patient on the same day. This modifier helps identify those procedures which are typically not reported together.
CPT Code 91065 – Billing & Reimbursement Guidelines
Insurance companies usually have specific conditions for breath test reimbursements. So, if you want to avoid claim denials, consider the following key aspects while billing for CPT code 91065.
Verify Insurance Coverage
Before performing a hydrogen breath test on any patient, verify whether it is included in their insurance plan. Some payers have coverage limitations. For example, Medicare’s coverage for this test is limited to detecting lactose malabsorption. In other words, it does not cover lactulose-based hydrogen breath tests necessary for diagnosing small bowel bacterial growth.
In short, insurance coverage verification is essential for avoiding financial losses and payment disputes.
Fulfill Documentation Requirements
Documentation can save you from payment delays as well as unexpected denials. Therefore, you must review payer-specific requirements and submit complete documentation to prove the hydrogen breath test’s medical necessity.
These include recording a patient’s relevant symptoms, such as diarrhea, nausea, and abdominal pain. Moreover, you should also include all those doctor’s notes that indicate a strong clinical suspicion of lactose malabsorption or other gastrointestinal issues.
Your diagnosis should be supported by an appropriate ICD-10-CM code and reflect the medical necessity of a hydrogen/methane breath test.
Understand & Comply with Payer-Specific Requirements
Always check every insurance company’s requirements before filing claims for CPT code 91065. Check their reimbursement criteria and coverage limitations. Also, confirm the National Coverage Determination (NCD) exclusions to avoid unexpected issues.
Use Modifiers Only When Required
Avoid the misuse of modifiers. CPT code 91065 typically does not require any modifier. But you can use them in certain circumstances. Another important consideration? If a doctor has ordered multiple hydrogen breath tests, they must be performed on separate days.
Therefore, avoid using repeat procedure modifiers, such as 91, 76, and 77, with this code unless they are genuinely necessary.
Conclusion
To summarize, hydrogen/methane breath tests are crucial for diagnosing several gut issues, including SIBO, IMO, and lactose intolerance. Therefore, the 91065 CPT code is used quite frequently in gastroenterology. Although most healthcare providers and practices apply it correctly, they still face claim denials due to non-compliance with payer-specific guidelines.
We have highlighted best practices for billing CPT code 91065 to help you avoid basic mistakes and receive timely payments. But if you need further assistance, contact our representatives for a consultation.
