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24.2.8 Helicobacter pylori (H. pylori)
H. pylori testing is a benefit using serology, stool, or breath tests. Serology testing for H. pylori is a noninvasive diagnostic procedure preferred for initial diagnosis but is not indicated once a diagnosis is made.
Stool testing for H. pylori is a noninvasive diagnostic procedure appropriate for both diagnosis and determining response to therapy.
Breath testing for H. pylori is a noninvasive diagnostic procedure utilizing analysis of breath samples to determine the presence of H. pylori.
If a follow-up breath or stool test is used to document the eradication of H. pylori, the medical record documentation must verify the history of previous complications:
• The client remains symptomatic after a treatment regimen for H. pylori.
•The client is asymptomatic after H. pylori eradication therapy, but has a history of hemorrhage, perforation, or outlet obstruction from peptic ulcer disease.
•The client has a history of ulcer on chronic nonsteroidal anti-inflammatory drugs (NSAID) or anticoagulant therapy.
H. pylori testing is not indicated or a benefit for any of the following:
•New onset, dyspepsia that is responsive to conservative treatment (e.g., withdrawal of NSAIDs or use of antisecretory agents). If this treatment does not prove successful in eliminating the symptoms, further testing may be indicated to determine the presence of H. pylori.
•Screening for H. pylori in asymptomatic clients.
•If there has been a negative endoscopy in the previous 6 weeks.
•An endoscopy is planned.
•H. pylori is of new onset and is still being treated.
Serology testing is not indicated or a benefit for monitoring response to therapy.
The following procedure codes may be reimbursed by the CSHCN Services Program:
•Serology testing, procedure codes 83009, 86677, and 87339.
•Stool testing, procedure code 87338.
•Breath testing, procedure codes 78267, 78268, 83013, and 83014.
These procedure codes are considered a clinical lab service and must be billed using type of service (TOS) 5. The interpretation/professional component TOS I is not separately reimbursed.
Serology testing is a benefit once per year when submitted for the same client by any provider with the appropriate diagnosis code.
Serology, stool, and breath testing may be considered for reimbursement with any of the following diagnosis codes:
|
Diagnosis Code
|
Description
|
|
1510
|
Malignant neoplasm of cardia
|
|
1511
|
Malignant neoplasm of pylorus
|
|
1512
|
Malignant neoplasm of pyloric antrum
|
|
1513
|
Malignant neoplasm of fundus of stomach
|
|
1514
|
Malignant neoplasm of body of stomach
|
|
1515
|
Malignant neoplasm of lesser curvature of stomach, unspecified
|
|
1516
|
Malignant neoplasm of greater curvature of stomach, unspecified
|
|
1518
|
Malignant neoplasm of other specified sites of stomach
|
|
1519
|
Malignant neoplasm of stomach, unspecified site
|
|
53100
|
Acute gastric ulcer with hemorrhage, without mention of obstruction
|
|
53101
|
Acute gastric ulcer with hemorrhage and obstruction
|
|
53110
|
Acute gastric ulcer with perforation, without mention of obstruction
|
|
53111
|
Acute gastric ulcer with perforation and obstruction
|
|
53120
|
Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction
|
|
53121
|
Acute gastric ulcer with hemorrhage, perforation, and obstruction
|
|
53130
|
Acute gastric ulcer without mention of hemorrhage, perforation, or obstruction
|
|
53131
|
Acute gastric ulcer without mention of hemorrhage or perforation, with obstruction
|
|
53140
|
Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction
|
|
53141
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Chronic or unspecified gastric ulcer with hemorrhage and obstruction
|
|
53150
|
Chronic or unspecified gastric ulcer with perforation, without mention of obstruction
|
|
53151
|
Chronic or unspecified gastric ulcer with perforation and obstruction
|
|
53160
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Chronic or unspecified gastric ulcer with hemorrhage and perforation, without mention of obstruction
|
|
53161
|
Chronic or unspecified gastric ulcer with hemorrhage, perforation, and obstruction
|
|
53170
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Chronic gastric ulcer without mention of hemorrhage, perforation, without mention of obstruction
|
|
53171
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Chronic gastric ulcer without mention of hemorrhage or perforation, with obstruction
|
|
53190
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Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage, perforation, or obstruction
|
|
53191
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Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction
|
|
53200
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Acute duodenal ulcer with hemorrhage, without mention of obstruction
|
|
53201
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Acute duodenal ulcer with hemorrhage and obstruction
|
|
53210
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Acute duodenal ulcer with perforation, without mention of obstruction
|
|
53211
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Acute duodenal ulcer with perforation, with obstruction
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|
53220
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Acute duodenal ulcer with hemorrhage and perforation, without mention of obstruction
|
|
53221
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Acute duodenal ulcer with hemorrhage, perforation, and obstruction
|
|
53230
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Acute duodenal ulcer without mention of hemorrhage, perforation, or obstruction
|
|
53231
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Acute duodenal ulcer without mention of hemorrhage or perforation, with obstruction
|
|
53240
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Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction
|
|
53241
|
Chronic or unspecified duodenal ulcer with hemorrhage and obstruction
|
|
53250
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Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction
|
|
53251
|
Chronic or unspecified duodenal ulcer with perforation and obstruction
|
|
53260
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Chronic or unspecified duodenal ulcer with hemorrhage and perforation, without mention of obstruction
|
|
53261
|
Chronic or unspecified duodenal ulcer with hemorrhage, perforation, and obstruction
|
|
53270
|
Chronic duodenal ulcer without mention of hemorrhage, perforation, or obstruction
|
|
53271
|
Chronic duodenal ulcer without mention of hemorrhage or perforation, with obstruction
|
|
53290
|
Duodenal ulcer, unspecified as acute or chronic, without hemorrhage, perforation, or obstruction
|
|
53291
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Duodenal ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction
|
|
53300
|
Acute peptic ulcer, unspecified site, with hemorrhage, without mention of obstruction
|
|
53301
|
Acute peptic ulcer, unspecified site, with hemorrhage and obstruction
|
|
53310
|
Acute peptic ulcer, unspecified site, with perforation, without mention of obstruction
|
|
53311
|
Acute peptic ulcer, unspecified site, with perforation and obstruction
|
|
53320
|
Acute peptic ulcer, unspecified site, with hemorrhage and perforation, without mention of obstruction
|
|
53321
|
Acute peptic ulcer, unspecified site, with hemorrhage, perforation, and obstruction
|
|
53330
|
Acute peptic ulcer, unspecified site, without mention of hemorrhage, perforation, or obstruction
|
|
53331
|
Acute peptic ulcer, unspecified site, without mention of hemorrhage and perforation, with obstruction
|
|
53340
|
Chronic or unspecified peptic ulcer, unspecified site, with hemorrhage and obstruction
|
|
53341
|
Chronic or unspecified peptic ulcer, unspecified site, with hemorrhage and obstruction
|
|
53350
|
Chronic or unspecified peptic ulcer, unspecified site, with perforation, without mention of obstruction
|
|
53351
|
Chronic or unspecified peptic ulcer, unspecified site, with perforation and obstruction
|
|
53360
|
Chronic or unspecified peptic ulcer, unspecified site, with hemorrhage and perforation, without mention of obstruction
|
|
53361
|
Chronic or unspecified peptic ulcer, unspecified site, with hemorrhage, perforation, and obstruction
|
|
53370
|
Chronic peptic ulcer, unspecified site, without mention of hemorrhage, perforation, or obstruction
|
|
53371
|
Chronic peptic ulcer of unspecified site without mention of hemorrhage or perforation, with obstruction
|
|
53390
|
Peptic ulcer, unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction
|
|
53391
|
Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage, perforation, or obstruction
|
|
53400
|
Acute gastrojejunal ulcer with hemorrhage, without mention of obstruction
|
|
53401
|
Acute gastrojejunal ulcer, with hemorrhage, and obstruction
|
|
53410
|
Acute gastrojejunal ulcer with perforation, without mention of obstruction
|
|
53411
|
Acute gastrojejunal ulcer with perforation, and obstruction
|
|
53420
|
Acute gastrojejunal ulcer with hemorrhage and perforation, without mention of obstruction
|
|
53421
|
Acute gastrojejunal ulcer with hemorrhage, perforation, or obstruction
|
|
53430
|
Acute gastrojejunal ulcer without mention of hemorrhage, perforation, or obstruction
|
|
53431
|
Acute gastrojejunal ulcer without mention of hemorrhage or perforation, with obstruction
|
|
53440
|
Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction
|
|
53441
|
Chronic or unspecified gastrojejunal ulcer, with hemorrhage and obstruction
|
|
53450
|
Chronic or unspecified gastrojejunal ulcer with perforation, without mention of obstruction
|
|
53451
|
Chronic or unspecified gastrojejunal ulcer with perforation and obstruction
|
|
53460
|
Chronic or unspecified gastrojejunal ulcer with hemorrhage and perforation, without mention of obstruction
|
|
53461
|
Chronic or unspecified gastrojejunal ulcer with hemorrhage, perforation, and obstruction
|
|
53470
|
Chronic gastrojejunal ulcer without mention of hemorrhage, perforation, or obstruction
|
|
53471
|
Chronic gastrojejunal ulcer without mention of hemorrhage or perforation, with obstruction
|
|
53490
|
Gastrojejunal ulcer, unspecified as acute or chronic, without mention of hemorrhage, perforation, or obstruction
|
|
53491
|
Gastrojejunal ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction
|
|
53500
|
Acute gastritis without mention of hemorrhage
|
|
53501
|
Acute gastritis with hemorrhage
|
|
53510
|
Atrophic gastritis without mention of hemorrhage
|
|
53511
|
Atrophic gastritis with hemorrhage
|
|
53520
|
Gastric mucosal hypertrophy without mention of hemorrhage
|
|
53521
|
Gastric mucosal hypertrophy with hemorrhage
|
|
53530
|
Alcoholic gastritis (without mention of hemorrhage)
|
|
53531
|
Alcoholic gastritis with hemorrhage
|
|
53540
|
Other specified gastritis without mention of hemorrhage
|
|
53541
|
Other specified gastritis with hemorrhage
|
|
53550
|
Unspecified gastritis and gastroduodenitis without mention of hemorrhage
|
|
53551
|
Unspecified gastritis and gastroduodenitis with hemorrhage
|
|
53560
|
Duodenitis without mention of hemorrhage
|
|
53561
|
Duodenitis with hemorrhage
|
|
5368
|
Dyspepsia and other specified disorders of function of stomach
|
In addition to the diagnosis codes listed in the preceding table, diagnosis code 04186, Helicobacter pylori (H. pylori), may be considered for reimbursement for breath and stool tests.
Only one of the following procedure codes may be reimbursed for the same date of service when billed by the same provider: 83009, 86677, 87338, or 87339.
The following procedure codes may not be submitted for reimbursement consideration with the same date of service by the same provider.
•If any combination of procedure codes 86677, 83009, 87338, and 83013 is submitted for reimbursement, only one of the procedure codes will be considered for reimbursement and the others will be denied as duplicate services.
•If any combination of procedure codes 86677, 83009, 87338, and 83014 is submitted for reimbursement, only one of the procedure codes will be considered for reimbursement and the others will be denied as duplicate services.
Procedure codes 83013 and 83014 may be considered for reimbursement for the same date of service.
Only breath tests C-13 (procedure codes 83013 and 83014) or C-14 (procedure codes 78267 and 78268) are payable on the same date of service.
C-13 or C-14 breath testing is not considered for reimbursement separately when it is submitted by the same provider with the same date of service as procedure codes 83009, 86677, 87338, or 87339.
If a follow-up breath or stool test is used to document the eradication of H. pylori, the medical record should contain evidence of one of the following:
•The patient remains symptomatic after a treatment regimen for H. pylori.
•The patient is asymptomatic after H. pylori eradication therapy but has a history of hemorrhage, perforation, or outlet obstruction from peptic ulcer disease.
•The patient has a history of ulcer on chronic nonsteroidal anti-inflammatory drug (NSAID) or anticoagulant therapy.
Providers cannot be reimbursed for testing for the eradication of H. pylori within 90 days of the initial testing.
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