Does 91111 require prior authorization?

No, 91111 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 91111?

Medicare facility rate: $28.24. Non-facility rate: $28.24. Work RVU: 0.88.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.88

Facility

$28.24

Non-Facility

$28.24

The patient's medical record must include the ordering provider's assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
For Patency Capsule Testing submitted for denial purposes, enter 'Patency Capsule Testing' in Item 19 of the CMS-1500 (or the electronic equivalent) and use CPT 91299; the ingestion is part of the test.
For Part A inpatient hospital claims, report the principal diagnosis in UB-04 FL 67, the admitting diagnosis in FL 69, and up to eight additional diagnoses in FLs 67A-67Q; for outpatient hospital claims, report the diagnosis in FL 67 or a symptom if no definitive diagnosis, and use Z00.00-Z13.9 if no referring diagnosis is available.

Capsule endoscopy (CPT 91110, 91111 global) is payable under Medicare Part B when performed in office (POS 11), independent diagnostic testing facility (POS 49), or independent clinic (POS 49).
Technical component codes 91110-TC and 91111-TC are payable under Part B in office (11), IDTF (49), independent clinic (49), federally qualified health center (50), and rural health clinic (72).
Professional component codes 91110-26 and 91111-26 are payable under Part B in office (11), outpatient hospital (19 and 22), inpatient hospital (21), independent clinic (49), and public health clinic (71).
When capsule endoscopy is normal but compelling symptoms persist, irritable bowel syndrome or abdominal pain diagnosis codes K58.0, K58.9, R10.11-R10.13, R10.2, R10.31-R10.33, or R10.84 are on the list of covered diagnoses and may be used.
Report Patency Capsule Testing using CPT 91299 and enter 'Patency Capsule Testing' in Item 19 of the CMS-1500 (or electronic equivalent); the ingestion of the capsule is part of the test.
Telemetric gastrointestinal capsule imaging includes a technical component (capsule provision, hookup, downloading/processing) and a professional component (image review and interpretation with report); report the technical component's place of service as the location where the image download to the computer is performed.

L33693 — Peripheral Venous Ultrasound

J09

L33774 — Wireless Capsule Endoscopy

J09

A56704 — Billing and Coding: Wireless Capsule Endoscopy

J09

L35007 — Vestibular and Audiologic Function Studies

J12

L35434 — Oximetry Services

Ask Verity about documentation requirements, denial risks, or coverage in your state.