CPT code 91110: Capsule endoscopy billing, rates, and guidelines

CPT code 91110 is the billable procedure code for gastrointestinal tract imaging by capsule endoscopy, esophagus through ileum, with physician interpretation and report. Billed globally from an office, it pays roughly $750 to $800 under the 2026 Medicare Physician Fee Schedule. In a hospital or ASC the physician bills 91110-26 for the interpretation alone, which pays far less. Gastroenterology practices file the code for obscure GI bleeding and suspected Crohn’s disease. Most denials come from a missing prior authorization, or from an ICD-10 code the payer does not accept.

In the American Medical Association’s CPT code set, 91110 opens the Gastrointestinal Imaging, Pressure Measurement and Manometric Studies subsection. That subsection runs from 91110 to 91125. Below are the descriptor, the 2026 rates, the facility split, the modifiers, the covered diagnoses, and the rest of the capsule endoscopy family.

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Key takeaways

CPT code 91110 covers small bowel wireless capsule endoscopy with physician interpretation, not esophageal (91111) or colon (91113) imaging.

The 2026 Medicare global rate is roughly $750 to $800 nationally, built from 24.02 total RVUs at the $33.4009 conversion factor.

A capsule study read in a hospital or ASC is billed 91110-26, which pays the interpretation only and is worth far less.

Most commercial payers and Medicare Advantage plans require prior authorization; traditional Medicare Parts A/B requires medical necessity documentation but not prior auth.

Pabau’s claims management tools automate ICD-10 pairing, prior authorization tracking, and pre-submission documentation checks for GI practices billing 91110.

CPT code 91110: Official descriptor and code details

CPT code 91110 describes “gastrointestinal tract imaging; intraluminal (eg, capsule endoscopy), esophagus through ileum, with physician interpretation and report.” In practice, the patient swallows a capsule that holds a miniature wireless camera. The camera photographs the small bowel as it travels through, and transmits the images to a recorder worn on the patient’s belt. The physician then reviews the recorded footage, interprets findings, and produces a written report.

The procedure is device-agnostic: 91110 applies regardless of whether the practice uses Given Imaging’s PillCam SB, Olympus EndoCapsule, or another cleared capsule system. Payers do not differentiate reimbursement by device brand under this code.

Clinical overview: What is capsule endoscopy and when is it appropriate?

Capsule endoscopy gives physicians a non-invasive view of the small intestine. Conventional upper and lower endoscopy cannot routinely reach that segment of the GI tract. Covered indications per Medicare Local Coverage Determinations (LCDs) and major commercial payer policies include:

• Obscure GI bleeding (overt or occult) after negative upper endoscopy and colonoscopy
• Suspected or known Crohn’s disease involving the small bowel, when conventional imaging is inconclusive
• Celiac disease monitoring for complications or refractory disease
• Hereditary polyposis syndromes (e.g., Peutz-Jeghers syndrome) requiring small bowel surveillance
• Suspected small bowel tumors or vascular malformations

Medical necessity documentation must tie each study to one of these accepted indications. Medicare Administrative Contractors (MACs) such as Novitas and CGS are explicit about the limits. A capsule study ordered for non-specific abdominal pain, with no prior workup, is typically denied on medical necessity grounds.

ICD-10 codes commonly paired with 91110

Pairing 91110 with the correct ICD-10-CM diagnosis code is one of the most critical steps in claim preparation. An unsupported or non-specific ICD-10 code is among the top three denial causes for this procedure. The table below lists the most frequently accepted pairings; always verify against the applicable MAC’s LCD before submitting.

Confirming the covered diagnosis at scheduling costs a phone call. Discovering the mismatch after the payer denies the claim costs an appeal and a rebill.

Medicare reimbursement rates in 2026

The figures below come from the 2026 Medicare Physician Fee Schedule (MPFS) and are national averages. Verify your own locality against the CMS Physician Fee Schedule lookup tool. Geographic Practice Cost Indices (GPCIs) adjust every rate by locality, so Manhattan, San Francisco, and Chicago all pay above the national average.

Check each remittance against the rate the claim should have earned as soon as it processes. A systematic underpayment on 91110 shows up within the first few claims, long before a year-end audit would find it.

Facility vs non-facility billing for CPT 91110

Where the capsule endoscopy is performed determines which billing scenario applies. This distinction is one of the most frequent sources of coding confusion for 91110.

A physician who owns the capsule equipment and works in an office bills 91110 with no modifier. That claim earns the non-facility rate, which carries the practice expense for the equipment. The same physician reading images at a hospital bills 91110-26 and is paid the professional component alone. The difference between the two is worth several hundred dollars per study.

Billing guidelines and coding rules

Getting the billing rules right before submission prevents the most common rejections. Practice management software like Pabau routes US claims through Claim.MD, our clearinghouse partner. That clearinghouse runs edits against the CPT and ICD-10 catalogs before the payer sees the claim. Key billing rules to enforce:

• One unit per procedure: Bill 91110 as one unit of service regardless of the length of the recording session or number of images captured.
• Capsule codes are mutually exclusive by date: 91110 (small bowel) and 91111 (esophagus) should not be billed on the same date of service. NCCI edits likely apply, so verify the current NCCI edit table before billing both on one claim.
• Global vs split billing: The global code covers both the technical component (capsule device, recording equipment) and the professional component (physician interpretation). Split billing with both -TC and -26 on the same claim from the same provider is not appropriate.
• Place of service matters: Using POS 11 (office) when the procedure was performed at a hospital generates an overpayment risk and payer audit trigger.
• Check the 837 electronic claim file: Confirm that the claim loop carries the correct POS, rendering provider NPI, and ICD-10 pointer before transmission.

Modifiers that apply to 91110

Documentation the payer expects

Incomplete documentation is the most common reason capsule endoscopy claims are denied on audit. A compliant claim needs each of these elements in the patient record before submission.

• Physician order or referral documenting the clinical indication and attesting medical necessity
• Medical necessity statement linking the specific ICD-10 diagnosis to the covered indication in the applicable LCD
• Prior authorization approval number (when required by the payer; see prior authorization section below)
• Patient consent form including disclosure of capsule retention risk
• Physician interpretation report with documented findings, images reviewed, and clinical impression, signed and dated
• Superbill or encounter record with CPT code 91110, applicable modifier, and linked ICD-10 code(s) clearly noted
• Evidence of prior workup for obscure GI bleeding indications (prior EGD and colonoscopy reports)

Attaching the full package to the claim cuts audit exposure. A pre-procedure checklist held in the patient’s record flags a missing consent or referral before the capsule is dispensed.

Prior authorization by payer type

Prior authorization requirements vary by payer type. Traditional Medicare (Parts A/B) does not require it for 91110. Medical necessity still has to be documented and aligned with the applicable MAC’s LCD. Most commercial payers and Medicare Advantage plans do require authorization before the procedure. Run insurance eligibility verification early in scheduling, so each patient’s plan rule is known before a date is set.

• Traditional Medicare (Parts A/B): No prior authorization required. Documentation of medical necessity and LCD compliance is mandatory.
• Medicare Advantage plans: Most plans require prior authorization. Requirements mirror commercial policies and may include a failed prior workup as a prerequisite.
• Major commercial payers (Aetna, BCBS, UnitedHealthcare): Prior authorization is generally required. Common prerequisites include negative EGD and colonoscopy, specific covered ICD-10 diagnosis, and ordering provider credentials.
• Typical documentation for prior auth submission: Clinical indication letter, prior procedure reports (EGD, colonoscopy), and supporting ICD-10 codes.

Verify requirements directly with each payer for the current plan year. Prior auth policies change annually, and they vary by plan tier inside the same insurer network.

Common claim denials and how to avoid them

Five scenarios account for most rejected 91110 claims. Each one has a fix that belongs upstream of the claim, in scheduling or in documentation, rather than in the appeal.

• Missing prior authorization: The claim reaches the payer without an authorization number. Fix: Build a pre-scheduling checklist that flags payer type and triggers the prior auth workflow before the procedure date is set.
• Non-covered ICD-10 diagnosis: A non-specific code (e.g., K59.9 functional intestinal disorder) is paired with 91110 without meeting the LCD’s covered indication criteria. Fix: Cross-reference every ICD-10 pairing against the applicable MAC LCD before claim submission.
• Missing physician interpretation report: The claim is submitted without a signed, dated interpretation report. Fix: Make the report a hard prerequisite in the billing workflow before the claim can be released.
• Duplicate or same-date conflict: 91110 and 91111 billed on the same date of service triggers an NCCI bundling edit. Fix: Verify the procedure matches the correct anatomical site and code before billing both on the same claim.
• Incorrect place of service: POS 11 used when the procedure was performed at an outpatient hospital. Fix: Confirm POS from the scheduling system before populating the claim form.

Pull a monthly report of your denial codes, sorted by procedure code and by reason category. A repeat pattern on 91110 points at the workflow feeding the claim, rather than at one coder’s slip.

Related CPT codes: The capsule endoscopy code family

The gastrointestinal CPT codes for capsule endoscopy break down by anatomical site. Choosing the wrong code is a common mistake when a patient has multiple GI complaints. The AAPC CPT code lookup can be used to verify current descriptors for each code in this family before billing.

How Pabau keeps 91110 claims clean before submission

Three checks decide whether a 91110 claim gets paid. The authorization has to be confirmed at scheduling. The ICD-10 code has to match the MAC’s LCD, and the interpretation report has to be signed before release. In a busy GI practice those three checks sit with three different people, and no single record holds all three.

Pabau’s medical claims management tools hold all three against the same appointment record. The authorization number, the diagnosis pointer, and the signed report travel with the claim instead of living in three inboxes.

Claims then go out through Claim.MD, our US clearinghouse partner, which validates the CPT and ICD-10 codes and builds the 837P file. A capsule study with a mismatched diagnosis or a missing -26 is flagged while you can still correct it.

Billing CPT 91110 without the paperwork headache

Pabau connects your GI practice’s claims workflow to Claim.MD, automating ICD-10 code pairing, prior auth tracking, and pre-submission documentation checks. See how it works for gastroenterology billing teams.

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Conclusion

CPT code 91110 is simple to select and awkward to get paid for. Denials trace back to the authorization, the diagnosis pointer, or the signed report. All three are settled long before anyone opens the claim.

Two habits protect the revenue. Confirm the payer’s authorization rule while the study is being scheduled, and check every remittance against the rate your place of service earns. An underpayment then surfaces within days instead of at a year-end audit.

Book a demo to see how Pabau keeps the authorization, the diagnosis, and the interpretation report attached to one GI appointment record.

Continue your research

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