Article Title

Implanted Capsule pH Monitoring for GERD 

Article Publication Date

08/01/2003

Article Beginning Effective Date

09/19/2003

Article Ending Effective Date

Article Text

In its Medical Position Statement (http://www3.us.elsevierhealth.com/gastro/policy/v110n6p1981.html), the American Gastroenterological Association lists the following guidelines for the clinical use of esophageal pH recording:

• Esophageal pH recording is indicated to document abnormal esophageal acid exposure in an endoscopy-negative patient being considered for surgical antireflux repair (pH study done after withholding antisecretory drug regimen for 1 week)
• Esophageal pH recording is indicated to evaluate patients after antireflux surgery who are suspected to have ongoing abnormal reflux (pH study done after withholding antisecretory drug regimen for 1 week).
• Esophageal pH recording is indicated to evaluate patients with either normal or equivocal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor therapy (pH study done after withholding antisecretory drug regimen for 1 week if the study is done to confirm excessive acid exposure or while taking the antisecretory drug regimen if symptom-reflux correlation is to be scored).
• Esophageal pH recording is possibly indicated to detect refractory reflux in patients with chest pain after cardiac evaluation using a symptom reflux association scheme, preferably the symptom association probability calculation (pH study done after a trial of proton pump inhibitor therapy for at least 4 weeks).
• Esophageal pH recording is possibly indicated to evaluate a patient with suspected otolaryngologic manifestations (laryngitis, pharyngitis, chronic cough) of gastroesophageal reflux disease after symptoms have failed to respond to at least 4 weeks of proton pump inhibitor therapy (pH study done while the patient continues taking their antisecretory drug regimen to document the adequacy of therapy).
• Esophageal pH recording is possibly indicated to document concomitant gastroesophageal reflux disease in an adult onset, nonallergic asthmatic suspected of having reflux-induced asthma (pH study done after withholding antisecretory drugs for 1 week). Note: a positive test does not prove causality!
• Esophageal pH recording is not indicated to detect or verify reflux esophagitis (this is an endoscopic diagnosis).
• Esophageal pH recording is not indicated to evaluate for "alkaline reflux."

Esophageal ph recordings can be obtained by a variety of techniques, one of which is the continuous measurement by a capsule that is temporarily implanted in the lower esophagus. The capsule transmits information about the ph levels to a receiver worn by the patient for up to 48 hours. Eventually, the capsule sloughs off the esophagus and passes through the GI tract.

In the absence of a National Coverage Decision (NCD) or a Local Medical Review Policy (LMRP), CIGNA Government Services will evaluate these claims on an individual case-by-case basis. The service must be performed by a qualified provider. Documentation in support of medical necessity and as to why this methodology was chosen over other modalities must be recorded in the medical record and available to Medicare for review upon request.

Coding Guidelines:

1. Please use CPT code 43499 (unlisted procedure, esophagus) and place the term "implanted capsule pH meter" in Field 19 of the CMS 1500 Form or the electronic equivalent.

2. This service consists of a technical portion (TC - provision of the capsule, hookup of the recording equipment, and uploading of the data) and a professional component (physician's interpretation with report).

3. The place of service for the technical component of the test should be reported as the location where the upload of the data to the computer is performed.

4. The professional component (modifier 26) may be billed in places of service 11 (office), 21(inpatient hospital), 22(outpatient hospital), and 24 (ASC).

5. The global service or technical component (modifier TC) may be billed in place of service 11 (office).

6. The date of service should be entered as the date the capsule is placed and the hook-up is performed, with a quantity of one (1), regardless of the number of days the device is worn.

7. The UPIN of the physician or qualified non-physician provider ordering the test must be included on the claim.

8. Endoscopy for the implantation of the device is not separately reimbursable.

9. Billing of an E/M service solely to report the placement of the capsule and hook-up of the equipment will be denied as part of another payable service.

Pricing:

Global $477.00
Technical component (modifier -TC) $349.00
Professional component (modifier -26) $128.00

Coverage Topic

Diagnostic Tests, X-rays, and Lab Services