Minerva Posted Wed 29th of December, 2010 15:10:02 PM
Does anyone know why Medicare doesn't pay for this CPT?
SuperCoder Answered Wed 29th of December, 2010 22:49:59 PM
CPT 78267 coded for the urea breath test is a noninvasive method of diagnosing a Helicobacter pylori infection of the stomach.
The denial for this code has to be studied in the context as below:
Firstly, in many states, you can’t bill the breath test on the same day as the office visit to Medicare. And with Medicaid, you can’t have the test and the reading on the same day. As long as we’re careful with these situations, we don’t have any trouble with reimbursement.
From Guidelines point of view, please consider the following clinical scenarios are appropriate for use of the H. pylori breath test:
1. patients with classic relatively uncomplicated symptoms of peptic ulcer disease for whom
antibiotic therapy is planned, if the H. pylori breath test is positive, and no gastrointestinal
endoscopy is planned,
2. patients who have nonspecific dyspeptic symptoms with a positive H. pylori serum
antibody test, and no endoscopy is planned,
3. an upper gastrointestinal contrast X-ray series has been done which shows a duodenal
ulcer or significant gastritis and/or duodenitis, and no endoscopy is planned, and/or;
4. there are persistent or recurrent symptoms six weeks after treatment for a documented H.
pylori infection, and no endoscopy is planned.
The H. pylori breath test is considered NOT medically necessary in the following situations:
1. Patients who are being screened for H. pylori infection in the absence of documented
upper gastrointestinal tract symptoms and/or pathology,
2. Patients who have had an upper gastrointestinal endoscopy within the preceding six weeks
or for whom an upper gastrointestinal endoscopy is planned,
3. Patients who have nonspecific dyspeptic symptoms with a negative H. pylori serum
antibody test, or;
4. Patients who are asymptomatic after treatment of an H. pylori infection (either proven or
suspected). Except in the situation of a history of a major complication of ulcer disease
such as bleeding, perforation, penetration, or multiple recurrences, in which case, an H.
pylori breath test may be used to document eradication of the infection in lieu of a followup
endoscopy. If a follow-up breath test is used to document eradication of H. pylori in the
asymptomatic patient, it is expected that medical record documentation should verify the
history of the previous complication.