Capsule Endoscopy — Reimbursement and Coding Guidance
Defines Priority Health's billing, coding, documentation, and coverage considerations for capsule endoscopy procedures for commercial, Medicare, and Medicaid members.
No material clinical or coverage changes in this revision.
Coverage and Documentation Requirements
General coverage and documentation requirements
Coverage is contingent on the member's benefit plan, appropriate place-of-service and medical necessity; complete documentation is required. Authorization may be required per the Provider Manual or for Medicare PSOD requirements.
ALL of the following
- Service must be covered under the member's benefit plan; determination of coverage is based on the member's specific benefit terms and is not guaranteed by authorization alone.
- Service must be medically necessary for the condition being treated; medical necessity and appropriateness of the setting remain required.
- Service must be furnished in an appropriate place of service consistent with the patient's medical needs and condition; authorization may be required for certain settings or services (see Provider Manual).
See place-of-service authorization guidance.
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