Hydrogen and methane breath tests are simple to perform and are frequently performed in gastroenterology practices. It is an important test to diagnose conditions like lactose intolerance. Medical billers use CPT code 91065 for its billing. However, despite the simplicity of the test, its billing is challenging and requires precision.
But still, many billers get it wrong, and the claims are denied. The reason? Incorrect medical coding and mistakes in the use of CPT code 91065. These mistakes cause claim denials, delays in payments, and a significant loss in revenue.
That’s why we have compiled this guide, so you don’t have to face any more denials. So, let’s start.
CPT Code 91065 Description
As we discussed above, CPT code 91065 is used to bill simple hydrogen and methane tests. The purpose of this test is to detect lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit. As we all know, that every other person has a GIT issue nowadays, due to unhealthy eating habits, the use of breath tests is very common.
In simple words, the CPT code 91065 represents a non-invasive diagnostic test used by gastroenterologists to diagnose digestive disorders by measuring the hydrogen and methane levels in the patient’s breath. This test is performed after giving a patient a specific carbohydrate substrate, like lactose, glucose, or lactulose.
The hydrogen and methane breath tests are non-invasive tests that gastroenterologists use to detect and diagnose digestive disorders. This is done by measuring the hydrogen and methane levels in the patient’s breath. Usually, this test is performed two times. Once before giving any substrate to the patient to set the benchmark values, and once after giving a patient a specific carbohydrate substrate, like lactose, glucose, or lactulose.
Let’s discuss the test process in more detail.
Initially, the patient is usually asked to limit their diet to only low-fiber foods, and if possible, stop taking any antibiotics or probiotics one week before the test. Breath samples of the patient are taken at the start as a baseline without any solution. After that, the patient consumes a solution containing the test substrate. Breath samples are collected at regular intervals, typically after every 15 to 30 minutes. This is done for up to two hours.
The samples are then analyzed to detect the hydrogen and methane levels. If the gases are elevated above normal, this indicates malabsorption or bacterial overgrowth in the gut.
The CPT code 91065 is very frequently used in medical billing, as digestive issues are very common. In fact, a study suggests that Small Intestinal Bacterial Overgrowth (SIBO) can affect up to 10-15% of the general population. This makes it essential to learn how to use the code properly.
Appropriate Use Cases for CPT Code 91065
Let’s now look at a couple of scenarios where the CPT code 91065 can be used for billing.
Lactose Intolerance Diagnosis
Suppose a 35 year old man comes to the doctor complaining about bloating and diarrhea. The symptoms developed after eating dairy products. Initially, the patient tried to treat the issues himself by taking a lactose-free diet for 2 weeks, but the symptoms persisted.
To diagnose the disease, the gastroenterologist orders a hydrogen breath test using lactose as the substrate to confirm lactose malabsorption. The doctor then files a claim with CPT code 91065. This is a classic use of code 91065, and insurance providers easily reimburse for it, given that the necessary documents are attached.
Fructose Malabsorption Testing
A 28-year-old patient experiences bloating and abdominal pain after consuming fruits and foods containing high-fructose corn syrup. Despite dietary modifications, symptoms continue. The gastroenterologist orders a hydrogen breath test using fructose as the substrate.
While this is a clinically valid use of CPT code 91065, insurance coverage may vary, with some payers requiring documentation of medical necessity.
Modifiers to Append with CPT Code 91065
The CPT code 91065 is a self-explaining code and usually does not require any modifiers. However, in some instances, you might have to append a modifier. The table below contains modifiers that can be used with 91065.
| Modifier | Description | Usage |
|---|---|---|
| Modifier 26 | Professional Component: The physician only interprets test results, not performing the technical aspect | Used in settings like hospitals where the technical part is separate |
| Modifier TC | Technical Component: Billing for the test’s performance, excluding interpretation | Typically used by labs or facilities performing the test |
| Modifier 59 | Distinct Procedural Service: Indicates the test is separate from other services on the same day | Prevents bundling issues with other procedures |
| Modifier 76 | Repeat Procedure by Same Physician: The same doctor repeats the test on the same day. | It is rare, as tests are usually spaced out and used for specific circumstances. |
| Modifier 77 | Repeat Procedure by Different Physician: Another physician repeats the test on the same day. | Applies when a different doctor performs the repeat test. |
| Modifier 91 | Repeat Clinical Diagnostic Test: Repeat tests to monitor a condition | Requires documentation to justify medical necessity |
It is important to note here that the overuse of modifiers 76, 77, and 91 must be avoided. Only use these modifiers when absolutely necessary. That’s because hydrogen breath tests are generally conducted on separate days to ensure accuracy.
Reimbursement Guidelines for CPT Code 91065
The following are some of the best practices and reimbursement guidelines for CPT code 91065.
Verify Insurance Coverage
Before conducting the test, verify the patient’s details and confirm that the patient’s insurance is active and covers the required test. Also, verify the payer’s policy. That’s important because Medicare reimburses CPT code 91065 for lactose malabsorption but not SIBO or other experimental uses.
Document Medical Necessity
Maintain and attach proper documentation with your claims. Include details like the patient’s symptoms (e.g., bloating, diarrhea), and any prior medications or interventions before the test like a lactose-free diet, and make sure to append the necessary ICD-10 codes. Insurance companies often deny claims lacking these details.
Reimbursement Insights
It is also important to be aware of the expected amount to be reimbursed. Reimbursement for CPT code 91065 varies by payer, location, and setting (facility vs. non-facility).
As per the latest Medicare Physician Fee Schedule, the average payment for the CPT code 91065 ranges between $62 and $90. Private insurers may offer higher rates, so review your fee schedules and contracts to set realistic expectations.
Final Thoughts on CPT Code 91065
Mastering the use of CPT code 91065 is essential for gastroenterology practices. By following the information and guidelines provided in this blog, you can accurately file breath test claims and reduce the chance of denials, which will, in turn, increase your revenue collection.
If you are still facing issues with your billing or want to outsource your billing operations, contact our consultants to get expert support and the best gastroenterology billing services.
