You have most probably reached this guide because you are having issues with CPT code 91010. Don’t worry, you are not the only one. Many billers find this code hard to bill.
This code is frequently used in gastroenterology practices and also has a high reimbursement rate. However, its denial can significantly affect your bottom line. That’s why our experts at NeuraBill have created this detailed guide.
We have structured this blog in a way that by the end, you will have all the information needed to bill this code correctly. So, let’s start.
CPT Code 91010 – Description
CPT code 91010 is defined as:
“Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report.”
This definition can be hard to understand for some of us. So, let’s try to break this down in simple words.
Code 91010 represents an esophageal motility study. Gastroenterologists use this code to study how effectively the esophagus moves food from the throat to the stomach. The procedure provides detailed information on esophageal muscle function, which otherwise is very hard to detect via other methods.
You might be wondering what exactly happens during this study. Let’s walk you through the test procedure.
The procedure itself is straightforward. It is performed using an instrument called a manometer. During the procedure, the manometer is attached to a thin tube (catheter), which is then inserted through the nose into the patient’s esophagus. Once the manometer is in place, the patient is asked to take small sips of water.
The manometer records the changes in pressure caused by swallowing at multiple points in the esophagus. Physicians then use these readings to create a detailed map of the muscle function.
Please note that, even though CPT code 91010 includes both the technical and professional components, you have to use modifiers TC and 26 for your part in the procedure. Not using these modifiers can lead to denials.
Appropriate Use Cases for CPT Code 91010
To help clear any confusion, here are a couple of real-world scenarios in which CPT 91010 can be used:
GERD Examination
For our first scenario, suppose that a patient visits a gastroenterologist. During the assessment, he shares that he is feeling persistent heartburn, chest pain, and acid regurgitation. He also tells the physician that he has tried over-the-counter antacids for six months, but nothing seems to work. Based on his evaluations and the symptoms shared by the patient, the physician suspects gastroesophageal reflux disease (GERD).
However, to confirm the diagnosis, the physician orders an esophageal manometry. The test results confirm GERD. In this scenario, the manometry study can be billed with CPT code 91010.
Esophageal Spasms
Here is another scenario.
Suppose a patient comes to the ER. He explains to the physician that he experienced sudden chest pain and is also having difficulty swallowing solid foods. He describes the feeling as a squeezing sensation in his chest after eating. The attending physician refers him to a gastroenterologist for assessment. The gastroenterologist suspects esophageal spasm, which is causing abnormal muscle contractions.
To confirm the diagnosis and evaluate the esophageal motility and muscle coordination, the physician orders a manometry test. The test results confirm the diagnosis. At the end, the billing team can use CPT code 91010 to bill the manometry test.
Modifiers to Append with CPT Code 91010
To clarify the circumstances in which the esophageal motility study was performed, you can use the following modifiers with CPT code 91010:
| Modifier | Description | When To Use |
|---|---|---|
| 26 | Professional Component | Used for interpretation and written report only, excluding the procedure itself. |
| TC | Technical Component | Used for the procedure and equipment use, excluding interpretation. |
| 52 | Reduced Service | Indicates that the service was performed, but reduced in scope from the full CPT 91010 description. |
| 53 | Discontinued Procedure | It is used when the procedure was started but stopped after anesthesia administration due to circumstances beyond the physician’s control. |
| 59 | Distinct Procedural Service | Service was separate and distinct from other services performed the same day. |
| 76 | Repeat by the Same Provider | The same physician repeated the study on the same day. |
| 77 | Repeat by a Different Provider | A different physician repeated the study on the same day. |
Reimbursement Guidelines for CPT Code 91010
The following guidelines ensure optimal billing for CPT code 91010 and minimize claim denials.
Provide Detailed Documentation
Your documentation is a shield against claim denials. The more comprehensive your medical records are, the stronger your shield becomes. So, the medical records must clearly establish the medical necessity for esophageal manometry testing.
This can include vital details such as patient history, presenting symptoms, previous diagnostic studies, and the clinical rationale for ordering the procedure.
Verify Reimbursement Rate
To get fair reimbursement for your claims, you must first know how much you are owed for 91010 claims. Every payer has its own reimbursement rate. However, Medicare’s national average reimbursement rate for CPT code 91010 is $209.28 for non-facility settings.
The amount varies for each MAC locality. To check the exact amount for your specific MAC, you can use the PFS Lookup Tool.
Final Thoughts on CPT Code 91010
With that, we have reached the end of this guide. We understand this is a lot of information to retain. So, let’s recap.
CPT code 91010 is used frequently in gastroenterology practices. It is used to bill an esophageal manometry study. For proper reimbursement, you must ensure that the code is used correctly and appropriate modifiers are appended. Also, make sure to provide comprehensive documentation.
However, managing medical billing and coding can be difficult with in-house billing teams. We recommend getting professional gastroenterology billing services from specialized third-party companies like NeuraBill.
