Wireless Capsule Endoscopy

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Contractor's Policy Number

03-02-R2

Contractor's Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LMRP Title

Wireless Capsule Endoscopy

AMA CPT Copyright Statement

CMS National Coverage Policy

Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

CMS Region

Region III

CMS Consortium

Northeast

Original Policy Effective Date

06/27/2003

Original Policy Ending Date

Revision Effective Date

03/22/2004

01/01/2004

Revision Ending Date

03/21/2004

12/31/2003

LMRP Description

Wireless capsule endoscopy is the process of using a miniature digital camera to visualize the entire length of the small intestine. After being swallowed, the camera is passively transported through the bowel as it creates two visual images per second. The images are transmitted to a recording unit which the patient wears during the process. The recorded images are then downloaded onto a computer where they can be examined as a video stream by the physician.

This technology is useful for the evaluation of gastrointestinal bleeding believed to be of small bowel origin.

Indications and Limitations of Coverage and/or Medical Necessity

The evaluation of small bowel bleeding usually involves visualization of the gastrointestinal mucosa. The most common bleeding sites are the upper gastrointestinal tract and colon. When these sites are excluded as the source of bleeding, an investigation of the small bowel may be indicated. It is in this setting that enteral capsular videoscopy may be used to visualize those parts of the gastrointestinal tract that cannot be viewed otherwise.

CPT/HCPCS Section & Benefit Category

Procedures/Professional Services (Temporary)

Type of Bill Code

13X, 14X

Revenue Codes

0750

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT or HCPCS Level II books for the long description of the following code:

91110

GI tract capsule endosc

Ó CPT American Medical Association

Not Otherwise Classified (NOC)

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid

Covered for:

555.0		Regional enteritis, small intestine
555.2		Regional enteritis, small intestine with large intestine
555.9		Regional enteritis, unspecified site
557.0		Acute vascular insufficiency of intestine
557.1		Chronic vascular insufficiency of intestine
557.9		Unspecified vascular insufficiency of intestine
558.1		Gastroenteritis and colitis due to radiation
558.2		Toxic gastroenteritis and colitis
558.3		Allergic gastroenteritis and colitis
558.9		Other and unspecified noninfectious gastroenteritis and colitis
562.02		Diverticulosis of small intestine with hemorrhage
562.03		Diverticulitis of small intestine with hemorrhage
569.82		Ulceration of intestine
569.84		Angiodysplasia of intestine,; without mention of hemorrhage
569.85		Angiodysplasia of intestine, with hemorrhage
569.86		Dieulafoy lesion (hemorrhagic) of intestine
578.1		Gastrointestinal hemorrhage; Blood in stool
578.9		Hemorrhage of gastrointestinal tract, unspecified
792.1		Non-specific abnormal findings in stool content

Diagnoses that Support Medical Necessity

As listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

ICD-9 Codes that DO NOT Support Medical Necessity

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Diagnoses that DO NOT Support Medical Necessity

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Reasons for Denial

All other indications not listed in the "Indications and Limitations of Coverage" section of this policy,
The service is for screening purposes,
The service is not medically necessary,
The medical record does not verify that the service described by the HCPCS code was provided, and;
The service does not follow the guidelines of this policy.

Non-covered ICD-9 Codes

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Non-covered Diagnoses

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Coding Guidelines

To report this service, use the appropriate HCPCS code G0262 with revenue code 320 or 329,
All of the coverage criteria must be met before this service can be reimbursed by Medicare,
Diagnosis (es) must be present on any claim submitted, and be coded to the highest level of specificity, and;
The diagnosis codes(s) must be representative of the patient's condition.

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request.

Utilization Guidelines

Medicare will monitor the utilization of this procedure through the Medical Review process.

Other Comments

Financial Responsibility:

Provider Liable

The provider of the service or the ordering physician must have notified the patient in writing, prior to the service, and obtained a signature verifying Advance Beneficiary Notice. Without prior notice, services denied as not medically necessary cannot be billed to the beneficiary. The provider is liable.

Beneficiary Liable

If there is clear evidence that the beneficiary was issued and signed an Advanced Beneficiary Notice (ABN) prior to the service, the liability rests with the beneficiary. Claims for dates of service prior to January 1, 2003 should contain the condition code 20 and occurrence code 32, with date to signify that an ABN was issued to the beneficiary. Absence of these codes will result in a provider liable determination

Claims for dates of service beginning January 1, 2003 should contain the occurrence code 32 with date to signify that an ABN was issued to the beneficiary. Absence of this code will result in a provider liable determination.

Reference: PM AB-02-168, CR 2415

Sources of Information and Basis for Decision

Appleyard, M., Glukhovsky, A., Swain, P. (2001). Wireless capsule diagnostic endoscopy for recurrent small-bowel bleeding. New England Journal of Medicine 344, 232-3.

Appleyard, M., Fireman, Z., Glukhovsky, A. et al (2000). A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small bowel lesions. Gastroenterology 119, 1431-8.

Costamagna, G., Shah, S.K., Riccioni, M. E., et al (2002). A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Gastroenterology 123, 999-1005.

Ell, C., Remke, S., May, A., et al, (2002). The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding. Endoscopy 34, 685-9.

Lewis, B.S., Swain, P. (2002) Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: Results of a pilot study. Gastrointest Endosc.56, 349-53.

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

Advisory Committee Meeting Date:

Start Date of Comment Period

03/10/2003

End Date of Comment Period

04/24/2003

Start Date of Notice Period

05/13/2003

Revision History

Number	Date	Change
03-02-R2	02/05/2004	Changed revenue code from 320 and 329 to 750.
03-02-R1	01/01/2004	Annual CPT update. G0262 discontinued, 91110 added to policy.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT Codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.