Motility and GI function studies billing and coding guidelines: a position paper of the American Motility Society

Organizing and Developing a GI Motility Lab in Community Practice: Challenges and Rewards

PURPOSE OF REVIEW

Neurogastroenterology and motility is a rapidly evolving subspecialty that encompasses over 33% of gastroenterological disorders, and up to 50% of referrals to gastroenterology practice. It includes common problems such as dysphagia, gastroesophageal reflux disease, irritable bowel syndrome, chronic constipation, gastroparesis, functional dyspepsia, gas/bloating, small intestinal bacterial overgrowth, food intolerance and fecal incontinence Standard diagnostic tests such as endoscopy or imaging are normal in these conditions. To define the underlying mechanism(s)/etiology of these disorders, diagnostic motility tests are often required. These are best performed by well-trained personnel in a dedicated motility laboratory. Our purpose is to provide an up-to-date overview on how to organize and develop a motility laboratory based on our collective experiences in setting up such facilities in academia and community practice.

RECENT FINDINGS

A lack of knowledge, training and facilities for providing diagnostic motility tests has led to suboptimal patient care. A motility laboratory is the hub for diagnostic and therapeutic motility procedures. Common procedures include esophageal function tests such as esophageal manometry and pH monitoring, anorectal function tests suchlike anorectal manometry, neurophysiology and balloon expulsion, dysbiosis and food intolerance tests such as hydrogen/methane breath tests, and gastrointestinal transit assessment. These tests provide an accurate diagnosis and guide clinical management including use of medications, biofeedback therapy, neuromodulation, behavioral therapies, evidence-based dietary interventions and endoscopic or surgical procedures. Further, there have been recent developments in billing and coding of motility procedures and training requirements that are not well known. This review provides a stepwise approach on how to set-up a motility laboratory in the community or academic practice and includes the rationale, infrastructure, staffing needs, commonly performed motility tests and their clinical utility, billing and coding strategies, training needs and economic considerations for setting up this service.

Esophageal function testing: Billing and coding update

Esophageal function testing is being increasingly utilized in diagnosis and management of esophageal disorders. There have been several recent technological advances in the field to allow practitioners the ability to more accurately assess and treat such conditions, but there has been a relative lack of education in the literature regarding the associated Common Procedural Terminology (CPT) codes and methods of reimbursement. This review, commissioned and supported by the American Neurogastroenterology and Motility Society Council, aims to summarize each of the CPT codes for esophageal function testing and show the trends of associated reimbursement, as well as recommend coding methods in a practical context. We also aim to encourage many of these codes to be reviewed on a gastrointestinal (GI) societal level, by providing evidence of both discrepancies in coding definitions and inadequate reimbursement in this new era of esophageal function testing.

Enhanced electrogastrography: A realistic way to salvage a promise that was never kept?

AIM

To enhance the clinical utility of electrogastrography (EGG), which has been recorded since 1922, but is clinically unutilized.

METHODS

An innovative method to salvage the promise of EGG is proposed by introducing a preliminary procedure, while maintaining the electrodes, standardized equipment, and signal processing utilized in the well-established EGG testing of today. The proposed enhanced EGG (EEGG) protocol involves swallowing an ingestible capsule containing miniature electronic oscillator embedded in an expandable, self-disintegratable, biocompatible pseudobesoar residing in the stomach for the duration of the test. The benefits of the proposed approach are outlined, tested and discussed in details.

RESULTS

Experiments were performed on eight mongrel dogs (6F, 4M, 23.8 ± 3.3 kg). Four were administered an active EEGG capsule, while the rest were given a deactivated (battery removed) capsule. Pharmacologically facilitated gastric motility revealed a significant (P < 0.01) Pearson correlation between gastric motility indices obtained by force transducers implanted directly on the stomach, and the motility indices obtained by EEGG. A particular emphasis was made on preserving standard EGG-related hardware and software in order to facilitate the introduction of the proposed EEGG in environments which already utilize standard EGG testing. The expanded intragastric pseudobezoar containing the miniature electronic oscillator was retained during the tests, and could be disintegrated on demand.

CONCLUSION

Enhancing standard EGG by an ingestible, self-expanding and self-disintegrating pseudobesoar containing a miniature electronic oscillator can be an important avenue for clinical applicability of this test.

Functional studies of the gastrointestinal tract in adult surgical clinics: when do they help?

Gut motility and visceral sensation are two important components of normal gastrointestinal (GI) tract function. Disordered gut motility and sensation can cause significant symptoms which not only pose a health burden to patients, but may also mimic structural diseases and may generate many surgical referrals from primary care. Unfortunately, diagnostic testing for disorders of function lags well behind that for structural disease. In this article we review common presentations of functional disorders in surgical clinics, and relevant testing modalities.

The gastrointestinal motility laboratory

Abnormalities of gastrointestinal (GI) motor function contribute directly or indirectly to a number of common clinical problems and account for significant health care-related expenditure. Proper evaluation of patients who have suspected GI motility disorders is important to ensure a correct diagnosis and to embark on an appropriate plan of treatment. The GI motility laboratory serves as an important area for patient evaluation in gastroenterology and is an essential element in any comprehensive digestive disease program. This article addresses important concepts in setting up and running an efficient and practical GI motility laboratory.

The gastrointestinal motility laboratory

Abnormalities of gastrointestinal (GI) motor function contribute directly or indirectly to a number of common clinical problems and account for significant health care-related expenditure. Proper evaluation of patients who have suspected GI motility disorders is important to ensure a correct diagnosis and to embark on an appropriate plan of treatment. The GI motility laboratory serves as an important area for patient evaluation in gastroenterology and is an essential element in any comprehensive digestive disease program. This article addresses important concepts in setting up and running an efficient and practical GI motility laboratory.

Altered esophageal sensory-motor function in patients with persistent symptoms after Nissen fundoplication

BACKGROUND

The pathophysiology of persistent gastroesophageal reflux disease (GERD) symptoms after antireflux surgery is unclear. We assessed esophageal sensorimotor function in patients with GERD before and after Nissen fundoplication (NF).

METHODS

Sensory and biomechanical properties were evaluated before surgery using impedance planimetry in 17 GERD patients and 16 healthy volunteers. All patients underwent standard laparoscopic NF. Eight GERD patients with persistent symptoms after surgery underwent repeat evaluations at least 12 months after surgery.

RESULTS

At baseline, GERD patients had lower thresholds for first perception (P < .001), discomfort (P < .001), and pain (P < .001) compared with controls. The esophagus was more reactive (P = .001) and less distensible (P = .04) in patients than controls. After NF, in patients with persistent symptoms, the sensory thresholds were unchanged (P > .05) but esophageal wall reactivity decreased (P = .001), and distensibility improved (P = .025).

CONCLUSIONS

NF improves esophageal biomechanical dysfunction but not the underlying hypersensitivity. Visceral hypersensitivity of the esophagus may explain persistent symptoms after NF.

Training in gastrointestinal motility

Gastrointestinal (GI) motility and functional GI disorders are common reasons for patients to see gastroenterologists. Knowledge of the evaluation and treatment of these disorders is important to appropriately care for these patients in clinical practice. Training in GI motility is important to GI fellows and their subsequent role as gastroenterologists. The aim of this paper is to discuss the importance of GI motility disorders for trainees in gastroenterology, provide some suggestions for training activities for GI fellows in GI motility, and discuss ways to address the unmet clinical need for caring for patients with GI motility disorders that gastroenterologists routinely see in their clinical practice.

American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis

This literature review and the recommendations herein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on May 16, 2004, and by the AGA Governing Board on September 23, 2004.