CPT Code 91065: Breath Test (e.g., H. pylori, Lactose Intolerance)

What is a breath test?

A breath test is a noninvasive diagnostic procedure that measures the concentration of certain gases in exhaled air to identify abnormalities in digestion or bacterial activity in the small intestine. These tests commonly detect hydrogen and methane, which are byproducts of bacterial fermentation. Patients are required to fast (usually 8–12 hours) before the test and then consume a sugar solution, often derived from dairy products like lactose or other fermentable carbohydrates.

There are different types of breath tests including:

• Lactose breath test (for lactose malabsorption or lactase deficiency)
• Fructose breath test
• SIBO breath test
• Urea breath test (commonly used for H. pylori, but not reported with 91065)

CPT code 91065 specifically applies to hydrogen or methane breath tests, excluding other types.

CPT code 91065 documentation requirements

To establish medical necessity and ensure reimbursement, clinical documentation must include the following:

Clinical indication

Note the reason for testing, such as abdominal pain, bloating, chronic diarrhea, or suspected small intestinal bacterial overgrowth.

Substance ingested and timing

Clearly document the ingested substrate (e.g., lactose, fructose) and the time intervals at which breath samples were collected throughout the test.

Interpretation of test results

Include an analysis of test results, particularly noting elevated hydrogen or methane levels and their implications.

Final clinical impression

Record the final interpretation (e.g., positive for fructose intolerance or SIBO), including how the findings inform future patient care decisions.

CPT code 91065 billing guidelines

Proper billing of CPT code 91065 requires attention to how the service is performed and reported:

Report only once per study

Only one unit of 91065 should be billed per complete test, regardless of how many breath samples are taken or how long the study lasts for the same patient.

Separate technical and professional components

If the test is split between the technical component (equipment, staff, setup) and the professional component (physician interpretation), use modifier TC and modifier 26 accordingly.

Documentation must support insurance coverage

Coverage depends on the insurance plan. Most payers require well-documented medical necessity, particularly symptoms or prior conditions supporting the need for a breath test.

Applicable modifiers for CPT code 91065

Use the following modifiers when applicable to ensure clarity and compliance in claims:

• Modifier 26 – Professional component: Used when billing only for interpreting the test results.
• Modifier TC – Technical component: Used when billing only for providing the testing equipment and supplies.
• Modifier 59 – Distinct procedural service: Indicates the test was performed separately from other services on the same day.
• Modifier 76 – Repeat procedure by same physician: Use when the procedure is repeated by the same provider on the same day due to inconclusive results.
• Modifier 77 – Repeat procedure by another physician: Indicates the procedure was repeated by a different physician.
• Modifier 91 – Repeat clinical diagnostic laboratory test: Used when the breath test is repeated to evaluate the progression or response to treatment.

Other related CPT codes

• 91060: Gastric saline load test
• 91010: Esophageal motility study
• 91200: Liver elastography
• 87081: Culture, presumptive, pathogenic organisms, screening