CPT Code 91110: Capsule Endoscopy Billing & Reimbursement Guide

CPT Code 91110 is the small bowel capsule code, esophagus through the ileum, with the interpretation of the physician. There are two things that decide whether it will be paid or not. The diagnosis pairing is number one, it proves a prior EGD (upper endoscopy) and colonoscopy. The second thing is whether the claim is split correctly into two parts, professional and technical components. 

What is CPT Code 91110?  

The CPT code 91110 description reads gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with physician interpretation and report. Now, let’s understand this code. The term “intraluminal” means that the capsule passes through the lumen which has a camera. It is not done from the outside like CT scan. What is “esophagus through ileum?” It is the range based on the anatomy. The last part of the small intestine is called ileum. So, this procedure code 91110 covers everything from the throat down to the small bowel. Now, the last part says physician interpretation which means the doctor is reading the images and writing the findings. 

How the Study Actually Works

The study works when the patient swallows the capsule. There is a miniature wireless camera that takes continuous photographs. The images transmit to a recorder the patient is wearing. And later, the physician reviews the footage. Why does this test exist? A standard EGD reaches down only as far as the start of the small intestine and colonoscopy reaches up only as far as its end. Thus, small bowel capsule endoscopy is how the middle section can be viewed.

One Code for Every Capsule Brand 

There are many manufacturers who create capsule systems. PillCam SB3, CapsoCam Plus, Olympus EndoCapsule. The cpt code for capsule endoscopy does not change with the brand. You bill capsule endoscopy CPT code 91110 regardless of which brands are used by the practice. Payers do not have a separate rate based on brands.

Three Names, One Procedure

There are several names used for one procedure. Capsule endoscopy, wireless capsule endoscopy, and video capsule endoscopy are the three names used. All these names refer to the same procedure. One CPT code 91110 covers all three names.

Applicable Modifiers for CPT Code 91110

There are four modifiers that need to be discussed here for understanding the billing of this CPT code. 

Modifier 26 and TC

A capsule study is basically two jobs. Someone supplied the capsule, set up the recording equipment and downloaded the data. This is the technical component (modifier TC). Likewise, someone will review the findings and write the interpretation. This is a professional component (modifier 26). CMS spells this out in its billing and coding article for wireless capsule endoscopy, A56704, which confirms that both 91110 and 91111 consist of a professional and a technical component. If your practice owns the equipment and your physician reads them, no modifier will be used as CPT code 91110 is a global code. If a hospital owns the equipment, 91110-TC is billed and the physician bills 91110-26.

52 Modifier 

This modifier says “reduced services.” If the capsule runs out of battery, moves slowly or anything happens that does not cover the entire range which is esophagus to ileum, modifier 52 is appended. This modifier helps to get paid for the service that actually happens. 

59 and XE Modifier 

The payer’s system bundles the procedures that are part of each other, and the NCCI edits are the list that decides it. When a small bowel capsule is performed with another endoscopic procedure, the NCCI edits may treat one as included in the other. Modifier 59 is the modifier that shows that these are distinct procedures. For the XE modifier, it means a separate encounter. 

GA Modifier 

Advance Beneficiary Notice (ABN) is a written notice that Medicare may not pay, so the patient has to bear the cost. Capsule endoscopy has some conditions related to the coverage for the patients. So, modifier GA with the cpt code for capsule endoscopy clearly shows that the ABN was sent and the patient signed it. So, the denial can be billed to the patient to avoid revenue losses.

Is Your Capsule Study Billed on the Right Half?

Global, 26, or TC depends on who owns the equipment and who reads the images. Billing the wrong half is not a denial risk, it is an overpayment, and it rarely gets caught until an audit does. We check the component logic on every capsule claim before it goes out.

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The Capsule Endoscopy CPT Code Family

Here is the capsule endoscopy CPT code family, what it covers and the coverage status.

Code	What it covers	Coverage status
91110	Esophagus through ileum — small bowel	Covered with medical necessity criteria
91111	Esophagus only	Covered; at least one MAC requires modifier KX
91113	Colon	Treated as investigational by MAC guidance
0651T	Magnetically controlled, esophagus through stomach	Category III; classified unproven / not reasonable and necessary by major payers

CPT Code 91110 – Billing & Reimbursement Guidelines

Under the Medicare Physician Fee Schedule, Medicare does not have a fixed price for every procedure. Each code is assigned a set of relative value units (RVUs) and these RVUs measure the amount of work done. It is a measure of what work was done, the practice expense, and the risk of malpractice. A total of these is multiplied by the conversion factor, now the relative value turns into actual money. One thing about this: there is a geographical adjustment on this calculation, so this is the reason why the same code is paid differently in different parts of the country. 

What Changed in 2026

For 2026, the conversion factor itself changed in a way no earlier guide accounts for. As required by statute, there are now two: $33.57 for practices that are qualifying participants in an alternative payment model, and $33.40 for everyone else, against a single 2025 conversion factor of $32.3465. The same capsule study, billed with the same code, pays differently depending on the practice’s APM status. CMS also applied a 2.5 percent efficiency adjustment to work RVUs for most non-time-based services this year, so any RVU total taken from a pre-2026 source is stale on both sides of the formula. 

Place of Service Rules for CPT Code 91110 

Place of service also decides where each version of the claim can come from. Global 91110 is payable in the office (POS 11), an IDTF, and an independent clinic. The technical component adds federally qualified health centers and rural health clinics. The professional component is payable from more settings, including outpatient and inpatient hospital, which makes sense because reading images is not tied to where the equipment sits. Getting these components and setting combinations right is routine work in gastroenterology billing services, and it is where most capsule claims are won or lost. 

Prior Authorization Requirements

Commercial plans and Medicare Advantage plans commonly require prior authorization for capsule endoscopy and the authorizations must be taken before the capsule is swallowed. 

Medical Necessity – ICD-10 Codes & Prior EGD/Colonoscopy Rule

Why does the patient need capsule endoscopy? It is necessary to prove this and dual diagnosis should be explained. As the capsule endoscopy is needed to see the small bowel where other scopes cannot reach. Medicare is clear on one thing: the capsule is not the first look, other scopes should have tried first. Therefore, the claim needs to prove two things at once: why the patient needs this imaging and what was already done. ICD-10 Z98.890 or Z98.891 is what tells about the prior endoscopy on the claim. If the claim fails to explain the necessity of the capsule endoscopy, CO-50 denial occurs that shows it is not medically necessary. 

The indications that show why capsule endoscopy was medically necessary: obscure gastrointestinal bleeding, in which the patient is losing blood somewhere. EGD and colonoscopy were unable to find anything, so it is the cleanest case for coverage. Moreover, there is a risk involved while swallowing the capsule as it has to pass naturally. It can get stuck (capsule retention) if there is narrowing in the bowel, a surgery may be needed to retrieve it. What is the solution? A patency capsule is given to the patient which is a dummy capsule and it dissolves to show that the path is clear. It is reported with 91299, but with the MAC guidance, as it is an unlisted code. Coverage details vary by MAC, so practices billed under Novitas or CGS should check their own contractor’s coverage article rather than relying on a general list, since these lists are revised over time.

Common CPT Code 91110 Denials & How to Prevent Them 

• CO-50, not medically necessary, is the first in the list. As discussed, if the pairing of the diagnosis fails, it leads to claim denial. Mostly, it is due to the absence of prior EGD/colonoscopy indicators. It can be prevented by adding dual diagnosis on every medical claim. This is the denial type our denial management services team sees most often on capsule claims. 
• CO-197, prior authorization is absent. Commercial and Medicare Advantage plans require prior authorization. You can get authorization before the patient swallows the capsule to prevent this denial.
• Incorrect component billed with the CPT Code 91110. When a facility uses its own equipment, global code is used, otherwise 26 for professional and TC for technical components.
•  Modifier 52 is not used when the ileum was not visualized as the study remained incomplete. Use this modifier as it says that the study is incomplete.
• For same day endoscopy procedures, check the NCCI edits before appending the XE or -59 modifier. 
• Not using the GA modifier when you had doubts about the coverage and there was no ABN on the file. To prevent this, send ABN and add the signed ABN in the claim, so the claim becomes patient responsibility. Most of these errors can be caught earlier in the PM/EHR and the clearinghouse is configured in such a way that it flags missing modifiers on capsule claims. 

Conclusion

CPT Code 91110 gets paid when all the things are lined up. The right component, the accurate diagnosis pairing, and the prior authorization when needed. Capsule endoscopy gets paid with the accurate documentation. As it is a risky procedure in terms of performing and billing, both, so take extra care while creating and submitting claims. Keep the documentation accurate and use accurate modifiers to get paid for video capsule endoscopy procedures. That discipline is the same one behind our medical billing services, applied to a code where a single missing indicator costs the whole claim.