2021 BILLING AND CODING GUIDELINES

1 2022 BILLING and CODING GUIDELINES PillCamTM small bowel capsule endoscopy 1 | The pillcam small bowel (SB) capsule endoscopy allows for direct visualization of the small bowel. A report is generated, which is reviewed by the physician. CPT 1 code 91110, gastrointestinal tract imaging, intraluminal ( , capsule endoscopy), esophagus through ileum, with interpretation and report. Placement in the Physician Office Patient presents to the physician office for ingestion of pillcam SB capsule endoscopy. Patient ingests the capsule and is fitted with the recorder device.

2 The patient will wear the device for the duration of the study and then return the recorder and the study results will be downloaded. The physician will review the results and document a report for the patient s medical record. pillcam SB capsule endoscopy in the physician office Professional charge 91110 Site of service 11 Date of service Date of report interpretation2 Providers may choose to report the technical (TC) and professional (26) portion of the capsule endoscopy procedure on separate dates. The decision to split bill the charge or to submit a global charge does not impact the coverage or allowable.

3 Placement in a Facility Setting When done in a facility, hospital inpatient or outpatient (HOPD) setting, both the facility and the provider will report a charge for their portion of the procedure provided. Patient presents to the facility for ingestion of pillcam SB capsule endoscopy. Patient ingests the capsule and is fitted with the recorder device. The patient will wear the device for the duration of the study and then return the recorder and the study results will be downloaded. The physician will review the results and document a report for the medical record.

4 2 | pillcam SB capsule endoscopy in the Inpatient or HOPD Professional charge 91110-263 Site of service 19, 21, or 22 Date of service Date of report interpretation2 Facility charge 91110 Date of service Date of capsule endoscopy All rates provided are for the Medicare national unadjusted average rounded to the nearest whole number for 2022 and do not represent adjustment specific to the provider s location or facility. CPT Code Description Physician4 Hospital Outpatient Department5 91110 Gastrointestinal tract imaging, intraluminal ( , capsule endoscopy), esophagus through ileum, with interpretation and report.

5 Physician office:$807 Inpatient/HOPD:$115 Work RVUs* $826 *RVU = Relative Value Unit If the patient is unable to swallow the capsule and it is placed endoscopically, a modifier may be needed to report that the procedure was reduced. These procedures are typically scheduled for the HOPD as 91110 is not included in the Medicare Ambulatory Surgical Center (ASC) fee schedule. Please check NCCI GUIDELINES to determine if the associated endoscopy can also be reported. When billed as part of an inpatient admission, payment will be included in the DRG.

6 For information related to medical policy for this product, please contact your Medtronic Reimbursement support team at 888-389-5200, option 1 or contact us via email at Additional support materials are available at 3 | Medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations.

7 The provider has the responsibility to determine medical necessity and to submit appropriate codes and charges for care provided. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of BILLING or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of CODING , coverage and payment policies.

8 This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling ( , instructions for use, operator s manual or package insert), consult with your BILLING advisors or payers on handling such BILLING issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. 1 CPT copyright 2021 American Medical Association.

9 All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 2 CMS has not issued definitive guidance as to the accurate date of service when services containing both a Technical and Professional component are not provided on the same date.

10 CODING convention suggestions that procedure charges should be reported on the day the work was completed. Please consult your internal CODING GUIDELINES . 3 For physician interpretation of the test in the facility setting modifier 26 is used to report that only the professional component of the procedure has been provided. 4 Centers for Medicare & Medicaid Services. Medicare Program; CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Federal Register (86 Fed. Reg.)