91110

Gastrointestinal tract imaging, intraluminal; wireless capsule endoscopy, esophagus through ileum, with or without remote data recorder, for capsule visualization and machine-assisted software review of images and detection of abnormalities; including physician interpretation and report

This procedure involves the patient ingesting a disposable wireless capsule equipped with a miniature camera. As the capsule traverses the gastrointestinal tract from the esophagus through the small intestine (duodenum, jejunum, and ileum), it captures thousands of images. These images are wirelessly transmitted to a portable data recorder worn by the patient. After the recording period, the data is downloaded from the recorder, and the images undergo machine-assisted software review for preliminary identification of potential abnormalities. A qualified physician then meticulously reviews and interprets the full set of images, provides a comprehensive report of the findings, and makes a diagnosis. This service encompasses all aspects from capsule ingestion to final report.

Clinical Indications

  • Investigation of obscure gastrointestinal bleeding (overt or occult) where upper endoscopy and colonoscopy are negative or inconclusive.
  • Suspicion of Crohn's disease or other inflammatory bowel disease affecting the small bowel.
  • Evaluation for small bowel tumors, polyps, or other structural lesions (e.g., angioectasias, ulcers).
  • Monitoring of known small bowel pathology, such as Celiac disease refractory to treatment or complications.
  • Diagnosis of chronic diarrhea or malabsorption syndromes where the etiology remains unknown after conventional workup.
  • Unexplained abdominal pain or iron deficiency anemia where other diagnostic tests have been negative.

Procedure Steps

  1. Patient fasts for a specified period (typically 8-12 hours) prior to the procedure.
  2. Patient is fitted with an external sensor array and a portable data recorder on their abdomen.
  3. Patient orally ingests the wireless capsule with a small amount of water.
  4. Patient is instructed on activity, food, and drink restrictions during the capsule's transit (usually 8-12 hours).
  5. Patient returns the data recorder after the prescribed recording period.
  6. Data is downloaded from the recorder to a dedicated workstation.
  7. Captured images undergo initial machine-assisted software review to aid in anomaly detection.
  8. A qualified physician systematically reviews the entire image series.
  9. Physician interprets the findings, correlates with clinical history, and generates a comprehensive diagnostic report.
  10. The capsule is naturally expelled from the body and is disposable.

Coding Guidelines

  • Code 91110 includes the ingestion of the capsule, recording of data, machine-assisted software review, physician interpretation, and report.
  • This code should be reported for studies covering the small bowel (esophagus through ileum). If the study only covers the esophagus, use CPT code 91112.
  • Do not report 91110 in conjunction with codes for other endoscopic procedures of the small bowel on the same date unless distinct and separately documented.
  • The code includes both the technical component (provision of capsule, data recorder, downloading, software review) and the professional component (physician interpretation and report).
  • Appropriate medical necessity must be documented in the patient's record to support the performance of the capsule endoscopy.
  • Always check payer-specific policies regarding coverage, medical necessity criteria, and prior authorization requirements for wireless capsule endoscopy.

Associated ICD-10 Codes