91112
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.05
Facility
$1767.24
Non-Facility
$1767.24
Documentation Required
- Providers must follow the billing, coding, and documentation requirements referenced in LCD L33455; this article provides supplementary coding guidance only.
- Documentation that the test is ordered and interpreted by a gastroenterologist trained to use and interpret the Wireless Motility Capsule.
- Documentation that basic clinical investigations, including endoscopy, were performed and failed to elucidate a diagnosis prior to WMC use.
- Documentation that the patient discontinued all medications that affect the gastrointestinal tract prior to performing the test.
Key Coverage Criteria
- Coverage and medical necessity for wireless gastrointestinal motility monitoring systems are determined according to Local Coverage Determination L33455.
- Coverage when used to evaluate patients with suspected delayed gastric emptying or gastroparesis of any etiology.
- Coverage when used to evaluate colonic transit in patients with chronic idiopathic constipation lasting more than 6 months.
- Coverage when used to determine gastrointestinal motility measures (gastric emptying, small bowel transit, colonic transit, whole gut transit, or intraluminal pressure patterns) in patients after basic clinical investigations, including endoscopy, have failed to elucidate a diagnosis.
- Colon motility (manometric) study, minimum 6 hours continuous recording (CPT 91117) — covered if selection criteria are met.
- CPT 78264 Gastric emptying imaging study (eg, solid, liquid, or both) — covered if selection criteria are met.
7 Active Policies
AMBETTER-CP.MP.143 — Wireless Motility Capsule
A56724 — Billing and Coding: Wireless Gastrointestinal Motility Monitoring Systems
L33455 — Wireless Gastrointestinal Motility Monitoring Systems
EVICORE-CAPSULE-ENDOSCOPY-GUIDELINES — Capsule Endoscopy Guidelines
AETNA-CPB-0396 — Gastrointestinal Function: Selected Tests
Related Codes
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