We understand that gastroenterology billing can be overwhelming due to complex coding, varying billing requirements, and changing regulations. Thus, we decided to cover the most commonly used gastroenterology CPT codes in individual guides to ensure we cover every aspect of each procedural code.
In this guide, we will discuss everything you need to know about CPT code 91200, scenarios where it may apply, a list of applicable modifiers, and its billing requirements.
Therefore, if you want to learn what this CPT code entails and how to report it to ensure rightful payment, you should read this guide till the end!
CPT Code 91200 – Description
The CPT code 91200 involves elastography to assess whether tumors in the liver are benign or nonmalignant and to differentiate a lesion from a normal tissue. This code covers both the professional and technical components of the procedure.
Tumors have lower elasticity and are less likely to return to their original shape after applying force when compared to normal tissues. Moreover, in comparison to cancerous tissues, nonmalignant tumors show more elasticity.
The elastography covered under this CPT code is non-imaging, commonly known as FibroScan®, which is a non-invasive technique to determine liver stiffness. It is a vital procedure used in the evaluation of liver scar tissue.
It is performed by placing a small handled probe, known as the FibroScan® probe, between the ribs on the right side of the lower chest wall. The technician then releases a series of ten painless pulses to the liver. The equipment records the results, and a liver stiffness score is generated. A physician interprets these results. The stiffer the liver, the faster the vibration will travel.
Scenarios Where CPT Code 91200 is Applicable
The following are a few illustrative examples where the CPT code 91200 may apply:
Identification of Benign and Malignant Liver Tumors
Assume a scenario in which a patient visits a healthcare provider with a suspicious liver mass detected on the imaging reports. The physician requests a liver elastography to determine the stiffness of the mass.
The findings will help the physician determine whether the mass is a benign or malignant tumor and how to proceed with the treatment plan. The physician will report CPT code 91200 for rightful payment since it covers the liver elastography procedure.
Liver Fibrosis Staging
Liver elastography is also performed on patients with chronic hepatitis C to assess the stage of liver fibrosis. Simply put, the test measures the stiffness of the liver, which correlates with the degree of scarring (fibrosis).
This information is vital and helps physicians in not only determining the stage of liver disease but also in choosing the appropriate treatment options. Thus, to bill for the liver elastography procedure, CPT code 91200 will be reported.
Liver Disease Treatment Response Monitoring
Let’s consider a patient with nonalcoholic steatohepatitis (NASH) who is undergoing treatment. As a result, the physician may order a series of liver elastography to monitor the patient’s response to therapy by evaluating changes in liver stiffness over time.
Thus, CPT code 91200 will be reported to bill each liver elastography procedure and ensure rightful reimbursement.
Applicable Modifiers for CPT Code 91200
Here is the list of applicable modifiers to ensure coding accuracy and specificity:
Modifier 26
You should append modifier 26 with CPT code 91200 when the physician has only interpreted the results of liver elastography and generated a written report. This modifier indicates to the payer that you are only billing for the professional component of the service.
Modifier TC
If the healthcare provider has performed the liver elastography procedure but was not involved in the interpretation of the results, then modifier TC is applicable. This modifier indicates that the technician is only billing for the technical component of the procedure, i.e., the equipment used and his time performing the service.
Modifier 59
This modifier helps you inform the payer that the liver elastography procedure is distinct and separately payable from other services rendered on the same service day. This modifier is crucial to avoid bundling issues and ensure proper reimbursements.
Modifier 76
What happens when the procedure identified by CPT code 91200 is repeated by the same healthcare practitioner on the same service date? You should append modifier 76 to highlight that the repeated service was necessary and not a duplicate billing error to avoid claim denials.
Modifier 77
You must add modifier 77 to the code 91200 if the liver elastography service was repeated by another clinician on the same service date. Appending this modifier is vital to indicate that the service repetition was necessary and should be reimbursed accordingly.
Modifier 91
In case the service is repeated due to clinical reasons, such as to confirm the initial results of the liver elastography on the same service date, appending modifier 91 to the CPT code 91200 is crucial to indicate the same to the payer.
Modifier 52
Modifier 52 is used when the procedure covered under the CPT code 91200 was performed less than what is typically required. It will help the insurance payer know that the service was either modified or partially completed due to specific circumstances.
Modifier 53
If the liver elastography was started but stopped due to unforeseen reasons beyond the physician’s control, such as patient safety, you should report modifier 53 with the CPT code.
Modifier 22
If the liver elastography procedure takes significantly more time, effort, or resources than is typically required due to technical challenges or any patient’s specific situation, then you must append modifier 22 with CPT code 91200. It will help you inform the payer that the procedure was more complex and should be rightfully reimbursed for the added difficulty.
Modifier 25
Report modifier 25 with the CPT code 91200 when a separately identifiable evaluation and management (E/M) service is rendered by the same healthcare provider on the same service date as the liver elastography.
CPT Code 91200 – Billing & Reimbursement Guidelines
Discussed below are the billing requirements and reimbursement guidelines of the CPT code 91200.
Establish Medical Necessity
Provide necessary documentation establishing the medical necessity and appropriateness of the liver elastography. Include the doctor’s notes and the reason behind conducting the test, such as liver fibrosis evaluation, liver disease severity assessment, liver transplantation donor evaluation, etc.
Ensure Documentation Correctness
Documentation completeness and accuracy are essential elements of medical claims. Thus, you must ensure your claim includes the patient’s medical record and current condition, the reason for performing the liver elastography procedure, the technique used, the results, and interpretation and recommendations by the healthcare provider.
Append Appropriate Modifers
The use of appropriate modifiers is another billing requirement of the CPT code 91200. For instance, we have already mentioned that this procedure code covers both the professional and technical components. Thus, if you want to bill a single element, i.e., for performing the procedure or the interpretation, you must append the relevant modifier.
For more details about the applicable modifiers, you can revisit the ‘applicable modifiers for CPT code 91200’, covered in the previous section of this guide.
Stay Updated on Payer Guidelines
Remember that all insurance payers, whether Medicare, Medicaid, or other private companies, have different billing requirements and reimbursement guidelines. Besides, insurance companies often update the rules for billing procedural codes.
Thus, we recommend you establish open lines of communication with the payers to stay current on the specific payer policies regarding the CPT code 91200. Compliance with these requirements will help you ensure timely and rightful reimbursements.
Summary
Let’s quickly summarize what we discussed in this guide. We explained the CPT code 91200 descriptor and how the liver elastography is performed. Besides, we shared some applicable scenarios related to this code, including determining the stage of liver fibrosis, monitoring liver disease treatment response, and differentiating between benign and malignant liver tumors.
We also listed all the applicable modifiers that can be appended to the liver elastography procedure to ensure coding accuracy and specificity. These included modifier TC, 22, 25, 26, 52, 53, 59, 76, 77, and 91. Moreover, we included the billing requirements to help you ensure error-free reporting. But, as a gastroenterologist or a gastroenterology practice, if you struggle to navigate through the complex landscape of medical billing, we advise you to outsource gastroenterology billing services to professionals like MediBillMD.
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