How To Use CPT Code 91110

CPT 91110 is a code for gastrointestinal tract imaging through capsule endoscopy, including interpretation and report. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 91110.

1. What is CPT 91110?

CPT 91110 is a medical billing code used for gastrointestinal tract imaging through capsule endoscopy, which involves the use of a small, ingestible camera to capture images of the digestive tract from the esophagus to the ileum. The code also includes the interpretation of the images and the preparation of a report by the healthcare provider.

2. 91110 CPT code description

The official description of CPT code 91110 is: “Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report.”

3. Procedure

1. The patient is appropriately prepped for the procedure.
2. The provider gives the patient an activated endoscopic capsule to swallow with normal water.
3. Natural peristaltic movement assists the movement of the capsule through the digestive tract.
4. As the capsule passes through the digestive tract, it automatically takes color images of the gastrointestinal lumen.
5. The provider places several image recording sensors on the patient’s abdomen.
6. An antenna at the base of the capsule sends the images to the recording device.
7. The provider leaves the patient for eight hours while the image recording takes place.
8. A complete procedure requires image recording from the upper esophagus to the terminal ileum. The provider may also take images of the colon.
9. The capsule passes out with a bowel movement within a day after completion of the procedure.
10. The provider transfers the data from the image recording device to the computer, analyzes and interprets the recorded data, and prepares a written report.

4. Qualifying circumstances

Patients who are eligible to receive CPT 91110 services are those experiencing gastrointestinal symptoms or conditions that require a detailed examination of the digestive tract. This may include patients with unexplained gastrointestinal bleeding, suspected inflammatory bowel disease, or other conditions that cannot be adequately diagnosed through traditional endoscopy or imaging techniques.

5. When to use CPT code 91110

It is appropriate to bill the 91110 CPT code when a healthcare provider performs a capsule endoscopy for gastrointestinal tract imaging from the esophagus to the ileum, interprets the results, and prepares a report for the service. This code should be used when the procedure is medically necessary and not for routine screening purposes.

6. Documentation requirements

To support a claim for CPT 91110, the healthcare provider must document the following information:

• Indication for the procedure, including the patient’s symptoms or conditions that necessitate the examination.
• Details of the procedure, including the type of capsule used, the placement of recording sensors, and the duration of the image recording.
• A summary of the findings, including any abnormalities or issues identified during the examination.
• The provider’s interpretation of the images and the preparation of a written report.

7. Billing guidelines

When billing for CPT code 91110, it is important to follow these guidelines:

• Append professional component modifier 26 if reporting only the professional component for the service.
• Append technical component modifier TC if reporting only the technical component for the service, unless the hospital provided the technical component. In that case, do not append modifier TC because the hospital’s portion is inherently technical.
• Do not append a professional or technical modifier to the code when reporting a global service in which one provider renders both the professional and technical components.
• Do not report CPT 91110 in conjunction with CPT 91111, CPT 91113, or CPT 0651T.
• Incidental visualization of the colon is not reported separately.
• Append modifier 52 if the ileum is not visualized.

8. Historical information

CPT 91110 was added to the Current Procedural Terminology system on January 1, 2004. The code was changed on January 1, 2013, with the previous descriptor being “Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with physician interpretation and report.”

9. Similar codes to CPT 91110

Five similar codes to CPT 91110 and how they differentiate from CPT 91110 are:

• CPT 91111: This code is used for gastrointestinal tract imaging through capsule endoscopy, but only for the esophagus.
• CPT 91113: This code is used for gastrointestinal tract imaging through colon capsule endoscopy, which focuses on the colon.
• CPT 0651T: This code is used for gastrointestinal tract imaging through capsule endoscopy with localization and monitoring.
• CPT 43235: This code is used for upper gastrointestinal endoscopy, which involves the use of a flexible endoscope rather than a capsule.
• CPT 45378: This code is used for diagnostic colonoscopy, which involves the use of a flexible endoscope to examine the colon.

10. Examples

Here are 10 detailed examples of CPT code 91110 procedures:

1. A patient with unexplained gastrointestinal bleeding undergoes a capsule endoscopy to identify the source of the bleeding.
2. A patient with suspected Crohn’s disease undergoes a capsule endoscopy to examine the small intestine for signs of inflammation.
3. A patient with a history of polyps undergoes a capsule endoscopy to monitor for the development of new polyps in the small intestine.
4. A patient with persistent abdominal pain undergoes a capsule endoscopy to rule out small bowel obstruction or other abnormalities.
5. A patient with iron deficiency anemia undergoes a capsule endoscopy to identify potential sources of blood loss in the gastrointestinal tract.
6. A patient with a family history of gastrointestinal cancer undergoes a capsule endoscopy to screen for early signs of malignancy.
7. A patient with suspected celiac disease undergoes a capsule endoscopy to assess the extent of damage to the small intestine.
8. A patient with a history of nonsteroidal anti-inflammatory drug (NSAID) use undergoes a capsule endoscopy to evaluate for potential small bowel ulcers.
9. A patient with unexplained diarrhea undergoes a capsule endoscopy to identify potential causes, such as microscopic colitis or small bowel bacterial overgrowth.
10. A patient with a history of small bowel surgery undergoes a capsule endoscopy to monitor for potential complications, such as adhesions or strictures.