Gastroenterology’s various procedures, from simple office visits to complex endoscopic procedures, complicate its billing. Besides, a gastroenterologist has to deal with multiple anatomical locations since the gastrointestinal tract encompasses various organs, each with its own code set, complications, modifier usage, and billing requirements.
Therefore, the billing specialists at MediBillMD decided to decode commonly used gastroenterology CPT codes in individual guides. This guide will discuss the CPT code 91010’s descriptor, its applicable modifiers, billing requirements, and some best-case scenarios.
Thus, if you want to learn more about this procedural code, you should read this guide till the end!
CPT Code 91010 – Description
The CPT code 91010 is from the code range ‘Upper Gastrointestinal Motility Studies’, maintained by the American Medical Association (AMA). It covers the professional and technical components of the esophageal manometry procedure.
The healthcare provider uses a manometer to analyze the esophageal muscle movement and pressure in a patient with gastroesophageal reflux disease (GERD). He also interprets the findings and generates a report.
Scenarios Where CPT Code 91010 is Applicable
Here are some practical scenarios where this CPT code may apply:
Typical GERD Investigation
Assume a patient visits a physician complaining of persistent heartburn, chest pain, and difficulty swallowing. The healthcare provider suspects GERD and requested esophageal manometry.
The study results reveal abnormal esophageal contractions and decreased lower esophageal sphincter pressure, confirming GERD diagnosis. Thus, the CPT code 91010 will be reported to bill for the esophageal manometry.
Confirming Achalasia Diagnosis
Consider a scenario where a patient visits the physician due to difficulty swallowing both liquids and solids. The clinician suspects achalasia, a motility disorder characterized by the inability of the lower esophageal sphincter to relax. As a result, the physician orders esophageal manometry.
The esophageal manometry study results show the absence of peristaltic waves and increased resting lower esophageal sphincter pressure, confirming the achalasia diagnosis. Here, CPT code 91010 is applicable.
Post Fundoplication Assessment
A patient undergoes a fundoplication, i.e., an anti-reflux surgery for treating severe GERD. However, even after the procedure, the patient experiences the symptoms.
Thus, the physician requests esophageal manometry to evaluate the effectiveness of the fundoplication and assess for any postoperative complications, such as esophageal stricture or dysmotility.
The CPT code 91010 will be used to bill for the esophageal manometry.
Applicable Modifiers for CPT Code 91010
Discussed below are some applicable modifiers for this procedural code:
Modifier 26
Append the modifier 26 when you only want to bill the professional component of the CPT code 91010, i.e., interpreting the results and generating a written report of the esophageal manometry study.
Modifier TC
Modifier TC is often used to bill the technical component of the esophageal manometry procedure. Simply put, the procedure itself and the equipment used, excluding the interpretation, are billed by adding this modifier with the CPT 91010.
Modifier 52
Modifier 52 indicates that the esophageal manometry service was reduced in scope to what is described under the CPT code 91010.
Modifier 53
What happens when the esophageal manometry covered under the CPT code 91010 was initially started but stopped before it was complete due to unforeseen circumstances beyond the physician’s control or due to the factors that threaten the patient’s well-being? You should append modifier 53 to highlight this to the payer.
Modifier 76
If the esophageal manometry study was repeated by the same healthcare provider on the same day, you should use modifier 76 with the CPT code.
Modifier 77
In cases where the esophageal manometry was repeated by another physician on the same day, modifier 77 would be applicable.
Modifier 59
If the esophageal manometry service was distinct and separately payable from other services rendered on the same day, use modifier 59 with CPT code 91010 to avoid bundling issues.
Modifier 91
If the procedure covered under the CPT code 91010 was repeated to obtain multiple test results or confirm the initial results, append the modifier 91 to indicate it to the insurance payer.
CPT Code 91010 – Billing & Reimbursement Guidelines
In this section, we will look into the billing requirements and reimbursement guidelines related to the CPT code 91010:
Establish Medical Necessity
Your documentation must establish the medical necessity of the esophageal manometry study covered under the CPT code 91010 and justify the appropriateness of the performed procedure.
Ensure Comprehensive Documentation
Documentation completeness and accuracy are necessary to ensure timely and rightful reimbursement against the CPT code 91010. It should include patient demographic details, patient symptoms due to which the physician ordered this diagnostic procedure, and clinical notes.
Also, document any complications during the procedure and variations from the standard protocol. Besides, you should record all the relevant data obtained during the study and physician interpretation if you are billing for both the professional and technical components as mentioned under this CPT code descriptor.
Append the Appropriate Modifier
This CPT code covers the professional and technical components of the esophageal manometry study. Thus, if you are billing for a single component, either for conducting the test and equipment use or for interpreting results and generating a written report, you must append the appropriate modifier to ensure fair payment.
For more details on the applicable modifiers, you can revisit the ‘Applicable Modifiers for CPT Code 91010’ discussed above.
Specific Payer Policies
Each payer, whether Medicare, Medicaid, or a private insurance company, has specific billing requirements and reimbursement guidelines. Therefore, it is crucial to review the specific payer policies before submitting a claim to avoid payment delays and denials.
Summary
This guide explained the CPT code 91010 descriptor and shared some practical scenarios where it may be reported. We also discussed the applicable modifiers for this CPT code, including modifiers 26, TC, 52, 53, 59, 76, 77, and 91.
Moreover, we looked into the billing and reimbursement guidelines related to esophageal manometry. These included establishing medical necessity, ensuring comprehensive documentation, appending appropriate modifiers, and compliance with specific payer policies. If, even after reviewing all these details, you still struggle to navigate the complex landscape of medical coding and billing, we recommend outsourcing gastroenterology billing services to professionals like MediBillMD.
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