ASGE members may submit coding inquiries electronically to codingquestions@asge.org. Each month ASGE gets dozens of questions from members. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Below is a question and a tip that could be beneficial to your practice.
Question
I am seeking coding assistance for the difference between CPT 91122, anorectal manometry, and 91120, rectal sensation, tone and compliance test. As I understand it, an anorectal manometry function test may include contraction, reflex, and sensitivity. A balloon may be engaged to assist. I do not understand how this differs from 91120 because it sounds like that is also focusing on sensation. Our MDs do a gradient balloon test which implies by the description of 91120 to be that, but many resources indicate a gradient test is also done with 91120. Some of our clinicians submit 91122, and some submit both CPT codes. Both of their reports contain much of the same information. The clinicians think they’re billing correctly, so a clearer definition is needed for us.
Answer
As you see in the description below, each test has a different component and often both are done at the same session. If both are done then 91120 and 91122 should be billed.
91120
The physician performs a rectal sensation tone and compliance test using graded balloon distention to evaluate anorectal pathology. Tone tests for relaxation or rigidity in the rectum. Compliance tests the distensibility of the rectum. Sensation tests for fullness and discomfort upon distention. The patient is asked to empty his or her bowels. The patient is placed in left lateral decubitus position with the head lowered 20 degrees. The physician inserts a two-lumen catheter containing a cylindrical bag into the rectum. One lumen is used to inflate the bag; the other is used to measure pressure within the bag. With the distal end of the bag 5 cm from the anal verge, the bag is inflated with air. Inflation is slowly increased, and sensation, tone, and compliance monitored. The balloon is deflated when the patient experiences discomfort and urgency lasting more than 30 seconds.
91122
The physician performs anorectal manometry to help in diagnosing constipation and/or incontinence due to myotonic dysfunction or suspected cases of Hirschsprung's Disease. Hirschsprung's Disease is a congenital absence of ganglion nerve cells in the plexus that innervates the colon and/or rectum to relax the internal anorectal sphincter in response to rectal distension. A manometry probe is advanced into the rectum after a digital exam. The probe is slowly withdrawn, taking continuous pressure measurements until the high-pressure area of the anal sphincters is located. With the patient relaxed, the "basal anal pressure" is recorded, and highest pressures are recorded as the patient performs a maximum squeeze. The manometry catheter is inserted again with a rectal balloon that is slowly inflated to the patient's first sensation of fullness and the volume is recorded. The anal sphincter response to the rectal distention is also recorded. Another manometry technique using a 3-balloon apparatus may also be employed in which pressure measurements are taken as the external, middle, and internal rectal balloons are inflated and deflated to note threshold levels and sphincter responses. The key in differentiation is the manometry probe. Most commonly, both diagnostic studies are done together.
Tip: New CMS Split-Shared Policy takes effect January 1, 2022
In the CY 2022 MPFS final rule, CMS refined its policies for split (or shared) E/M visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services.. Practices will need to educate all providers on this new policy and provide sample documentation to ensure that the claim is submitted under the provider who provided the substantive portion of the encounter. The following changes are effective January 1.
- Definition of split (or shared) E/M visits as E/M visits provided in the facility setting by a physician and an NPP in the same group. The visit is billed by the physician or practitioner who provides the substantive portion of the visit.
- For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time. Time needs to be documented in minutes by each provider not just a percentage of time). Split (or shared) visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services.
- Modifier FS is required on the claim to identify a split or shared evaluation and management visit. Assign on the claim when billed under the physician.
- Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record.
- The documentation must support at least one of the providers had a face-to-face (in person) encounter with the patient, but it does not necessarily have to be the provider who performed the substantive portion and bills for the visit.
- For non-critical care encounters, if history, exam, or MDM is used as the substantive portion of the encounter in lieu of time, the documentation must reflect the billing provider performed the component in its entirety. Overlapping time may not be counted.