91035

Clinical Indications

• Evaluation of non-cardiac chest pain where cardiac etiologies have been excluded.
• Assessment of dysphagia (difficulty swallowing) or odynophagia (painful swallowing) when structural abnormalities have been ruled out by endoscopy.
• Diagnosis of non-erosive reflux disease (NERD) or functional heartburn, particularly when endoscopy is normal but reflux symptoms are prominent.
• Differentiation of symptoms related to gastroesophageal reflux disease (GERD) from other esophageal disorders or esophageal hypersensitivity.
• Preoperative evaluation before anti-reflux surgery (e.g., Nissen fundoplication) to assess esophageal motility and confirm the esophagus's role in symptoms.

Procedure Steps

1. Patient Preparation: Instruct the patient to fast for 6-8 hours prior to the procedure; review and adjust medications that may affect esophageal motility or acid secretion.
2. Catheter Placement: A multi-lumen manometry catheter is lubricated and carefully passed transnasally or transorally into the esophagus, with pressure sensors positioned at the UES, esophageal body, and LES.
3. Esophageal Manometry: Baseline esophageal pressures and motor activity are recorded during a series of dry and wet swallows (e.g., 5-10 ml water boluses) to assess peristalsis, contraction amplitude, and sphincter function.
4. Acid Perfusion (Bernstein Test): With the catheter tip positioned in the mid-esophagus, a control solution (e.g., normal saline) is infused at a controlled rate (e.g., 6-10 ml/min) for a specified period (e.g., 10-15 minutes) while monitoring for symptoms.
5. Acid Challenge: Dilute hydrochloric acid (e.g., 0.1 N HCl) is then infused at the same rate and location, and the patient's symptoms (e.g., chest pain, burning, discomfort) are meticulously monitored and documented.
6. Symptom Documentation: The exact time of symptom onset, description of symptoms, severity, and correlation with acid infusion are recorded. Relief of symptoms with subsequent saline infusion or antacids is also noted.
7. Data Analysis and Interpretation: Manometry tracings are analyzed for patterns of peristalsis, LES pressure, and coordination. The symptom response to acid perfusion is interpreted in conjunction with manometry findings to formulate a diagnosis.
8. Report Generation: A comprehensive report is prepared, detailing all manometric findings, the results of the acid perfusion study, and a final interpretation.

Coding Guidelines

• CPT 91035 includes both esophageal manometry and acid perfusion studies; therefore, it should not be reported separately with individual codes for basic esophageal manometry (e.g., 91010, 91011, 91012) or standalone acid perfusion tests.
• Medical necessity for the procedure must be clearly documented in the patient's medical record, including clinical indications, test results, and the impact on patient management.
• This code typically covers both the technical and professional components of the service. If performed in a facility setting, appropriate modifiers (e.g., TC for technical, 26 for professional) may be necessary depending on payer rules and billing arrangements.
• CPT 91035 is a diagnostic procedure and generally has a zero-day global period. It is typically not bundled with other major procedures unless performed for distinct indications and properly documented with modifier 59 (Distinct Procedural Service).
• Repeat studies require strong medical justification documenting a change in clinical status, new symptoms, or to evaluate the efficacy of a new treatment.

Associated ICD-10 Codes

• R07.2 - Precordial pain
• K21.9 - Gastro-esophageal reflux disease without esophagitis
• K22.4 - Dyskinesia of esophagus
• R13.19 - Other dysphagia
• R10.13 - Epigastric pain