Gastroesophageal reflux disease (GERD) is a common condition encountered in gastroenterology (GI) practices. While diagnosing GERD may be straightforward, accurately coding diagnostic procedures like esophageal motility studies can be more complex.
This guide will discuss everything you need to know about one such procedural code used to report GERD diagnosis, i.e., the CPT code 91035.
Thus, if you are a GI facility or a gastroenterologist, we recommend you read this guide till the end. It will help you attain the necessary knowledge and mitigate the risk of denials.
So, without further ado, let’s get started!
CPT Code 91035 – Description
This CPT code is from the code range ‘Gastroesophageal Reflux Test Studies’, maintained by the American Medical Association (AMA). It covers both the technical and professional components. The code reports the gastroesophageal reflux test with telemetry pH electrode placement (utilizing a Bravo capsule or Bravo pH Monitoring system) to determine the backflow of acid from the stomach into the esophagus, its results, interpretation, and reporting.
Scenarios Where CPT Code 91035 is Applicable
Discussed below are some real-world scenarios where the CPT code 91035 may apply:
GERD and Dysphagia
Let’s say a patient with a known hiatal hernia visits the physician with complaints about having increased difficulty swallowing liquids and solids, i.e., experiencing a sensation of food getting stuck in the chest.
Thus, the healthcare provider ordered a 24-hour pH monitoring test (gastroesophageal reflux test) covered under the CPT code 91035 to assess the role of acid reflux in the patient’s dysphagia. The test result revealed significant acid reflux, especially after meals. These findings helped the clinician treat the patient’s GERD through medication.
Infant GERD Evaluation
Assume a scenario in which a guardian brings their 24-month-old infant to a pediatrician with complaints about poor weight gain, frequent spitting, and severe irritability after every feeding. The pediatrician, suspecting GERD, requests a 24-hour gastroesophageal reflux test to confirm the diagnosis and determine the severity of the reflux.
The results reveal significant acid reflux during and after feedings, and a treatment plan is made accordingly to reduce the symptoms and improve the child’s feedings. Thus, CPT code 91035 will be reported since its descriptor precisely matches the pH monitoring test.
GERD Exacerbating Asthma
What happens when a patient with an asthma history experiences worsened asthma symptoms despite using the prescribed inhalers? The healthcare provider may order a 24-hour pH monitoring test to confirm the suspected GERD as the contributing factor to increased respiratory issues.
The test results revealed significant acid reflux, particularly at night. As a result, the physician added a proton pump inhibitor (PPI) medication to the patient’s treatment plan. Here, CPT code 91035 is applicable to bill for the gastroesophageal reflux test over a specified period, which helped the provider confirm the diagnosis and update the care plan.
Applicable Modifiers for CPT Code 91035
Below is the list of medical modifiers that can be appended to code 91035. It will help you ensure coding specificity for accurate reimbursements.
Modifier 26
If you want to bill only the professional component of the procedure covered under CPT code 91035, you should submit the medical claim with modifier 26. This modifier indicates that you are seeking reimbursement only for interpreting the findings and preparing the report of the G-esoph reflex test with electrodes.
Modifier TC
You should append modifier TC to the CPT code 91035 when you handled the technical component of the pH monitoring test for a specific period, excluding the professional component. It means that you are only billing for the performance of the procedure, equipment use, and personnel involved.
Modifier 52
When you start the procedure but it was partially reduced, or some services were eliminated at the physician’s discretion, add modifier 52 to the CPT code to ensure rightful reimbursement against the services.
Modifier 53
The physician may encounter uncertain and unforeseen circumstances beyond their control, such as patient safety concerns, leading to the discontinuation of the gastroesophageal reflux test before it was completed. In such cases, you should report the CPT code 91035 with modifier 53 to highlight this to the payer and ensure rightful payment.
Modifier 59
You may append this modifier to the CPT code 91035 to indicate that the performed G-esoph reflex test with electrodes is distinct and eligible for separate reimbursement from other procedures rendered on the same day. This modifier helps you avoid bundling-related denials.
Modifier 76
You should use modifier 76 if the pH monitoring test described under the CPT code 91035 is repeated by the same healthcare practitioner on the same day. This modifier explains to the insurance payer that the repetition was necessary, mitigating the risk of ‘duplicate billing’ denials.
Modifier 77
You should append modifier 77 to CPT 91035 when a different physician repeats the gastroesophageal reflux test on the same day.
Modifier 91
When the procedure covered under CPT code 91035 is repeated for clinical reasons, such as obtaining subsequent test results or confirming the initial results, append modifier 91 to highlight the same to the payer.
CPT Code 91035 – Billing & Reimbursement Guidelines
The following are the billing requirements related to this CPT code:
Bravo Capsule Placement and Endoscopy
When the healthcare provider renders the Bravo capsule test (gastroesophageal reflux test with mucosal attached telemetry pH electrode placement with an endoscopy), there can be two billing criteria. For instance, the endoscopy is not separately payable if the physician performed it solely to measure the distance from teeth to the lower esophageal sphincter for placement of the Bravo capsule. Hence, you should only report the CPT code 91035.
Contrarily, if a physician performed a medically necessary esophagogastroduodenoscopy (EGD) (CPT code 43235) to assess the symptoms and determine the location for Bravo capsule placement, you can bill the EGD separately from the test. However, note that you should report the EGD on the date of service (DOS), while CPT 91035 should be billed on the day the physician interprets the test results, i.e., a few days after the capsule placement.
CPT Code 91035 and Other Procedures
According to the billing guidelines described by AAPC, there are no NCCI edits that prevent you from reporting the CPT code 91035 with pH monitoring through a nasal catheter (CPT 91034) and esophageal manometry (CPT 91010). Therefore, you can bill all three procedures on the same day without appending modifiers (e.g., 59).
Billing 91035 with E/M Services
When a distinct and medically necessary evaluation and management (E/M) service is provided on the same day as the procedure covered under CPT code 91035, you can bill the E/M code individually by appending modifier 25.
Separately Payable Components
As discussed earlier, CPT code 91035 involves two components, i.e., professional and technical. Thus, if you want to bill a single component, you can do so by appending the relevant modifier.
For instance, if the healthcare provider interpreted the results and prepared the test report but did not own equipment, i.e., ordered the technical component from a facility, he will bill CPT code 91035 with modifier 26 (professional component), and the healthcare facility will report it with modifier TC (technical component).
However, if the physician owns the equipment and performs the professional component, 91035 is billed without these two modifiers.
Summary
Let’s quickly revisit what we learned in this guide! We explained the CPT code 91035 descriptor. We also shared some scenarios where this code (indicating a gastroesophageal reflux test with electrodes) may apply, including GERD with dysphagia, infant GERD evaluation, and GERD exacerbating asthma.
Besides, we discussed all the applicable modifiers to help you ensure coding specificity and accurate reimbursements. These included modifiers 26, TC, 52, 53, 59, 76, 77, and 91. Moreover, we shared the billing requirements related to this procedural code.
If, even after reading all the information related to the billing of this CPT code, you still find it challenging to manage medical billing in-house, we recommend outsourcing to professionals like MediBillMD. Their gastroenterology billing services include accurate CPT coding at the hands of AAPC-certified medical coders.
Frequently Asked Questions
