Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part B services billed on dates of service from January 1, 2024, through December 31, 2025. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Wireless capsule endoscopy (WCE) and colon capsule endoscopy (CCE) are diagnostic tests that may be used as an adjunctive tool in the detection of certain gastrointestinal (GI) conditions. The WCE evaluates the esophagus and small bowel, and the CCE evaluates the large bowel. These procedures do not require sedation and involve the beneficiary swallowing a small capsule that contains a disposable light source, miniature color video camera, battery, antenna, and data transmitter. The camera records images of the digestive system and transmits those images to the data recorder which is worn by the beneficiary. The images on the data recorder are downloaded to a computer where they are reviewed and interpreted by a physician. The capsule passes naturally through normal bowel function.

According to National Coverage Determination (NCD) 100.2 Endoscopy, Medicare Part B covers endoscopic procedures when the procedure is reasonable and necessary for the beneficiary. Local Coverage Determinations (LCD) outline the reasonable and medically necessary criteria for WCE and CCE.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with CPT codes 91110, 91111, and 91113 billed with date of service January 1, 2024, through December 31, 2025.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. History and Physical reports (include medical history and current list of medications)
2. Physician/Non-Physician Practitioner medical record documentation to include pre-existing condition(s), previous treatment(s), and procedure(s)
3. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
4. Previous upper and/or lower endoscopy procedure results and interpretations (of any type)
5. Medical record documentation to support the suspected diagnosis(es) to necessitate the wireless capsule endoscopy procedure
6. Medical record documentation to support national and local requirements
7. Providers and/or suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available. Please include a signature log or signature attestation for any missing or illegible signature within the medical record.
8. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
9. Any other supporting/pertinent documentation
10. If medical record documentation is submitted via esMD Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
11. Please Note: The billing provider is responsible for obtaining all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References

Social Security Act (SSA), Title XVIII

• §1815(a) Payment to Providers of Services
• §1833(e) Payment of Benefits
• §1861(s)(2)(C) Medical and Other Health Services
• §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• §1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• §1893(b) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• §410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions
• §410.33 Independent diagnostic testing facility
• §411.15(k)(1) Particular services excluded from coverage
• §414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier
• §424.5(a)(6) Basic Conditions

Internet-Only Manual (IOM), Publication (Pub.) 100-03, National Coverage Determination Manual (NCD)

• §100.2 Endoscopy

IOM, Pub. 100-02, Medicare Benefit Policy Manual (MBPM)

• Chapter (Ch.) 6, §20.4 Outpatient Diagnostic Services
• Ch. 15, §30 Physician Services
• Ch. 15, §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
• Ch. 16, §20 Services Not Reasonable and Necessary

IOM, Pub. 100-04, Medicare Claims Processing Manual (MCPM)

• Ch. 1 General Billing Requirements
• Ch. 23, §10.1 – 10.1.7 Reporting ICD Diagnosis and Procedure Codes
• Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

IOM, Pub. 100-08, Medicare Program Integrity Manual (MPIM)

• Ch. 3 Verifying Potential Errors and Taking Corrective Actions
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Ch. 1, §C. Medical/Surgical Package. Effective January 1, 2020

Local Coverage Determination (LCD)

• L33774 Wireless Capsule Endoscopy
• L34081 Endoscopy By Capsule
• L35089 Wireless Capsule Endoscopy
• L36427 Wireless Capsule Endoscopy
• L38807 Colon Capsule Endoscopy (CCE)

Local Coverage Article (LCA)

• A56461 Billing and Coding: Endoscopy by Capsule
• A56704 Billing and Coding: Wireless Capsule Endoscopy
• A56727 Billing and Coding: Wireless Capsule Endoscopy
• A57753 Billing and Coding: Wireless Capsule Endoscopy
• A58414 Billing and Coding: Colon Capsule Endoscopy (CCE)

Other

• U.S. Food and Drug Administration (FDA) 510(k) Premarket Notification website. Retrieved from FDA Website

Last Updated May 26, 2026