Stomach motility complaints can quietly drain both clinical time and revenue. Patients with chronic nausea, early satiety, bloating, or post‑surgical symptoms often cycle through endoscopy, CT, and labs without a clear answer. When motility is the real issue, the gastric emptying study (GES) is the test that moves the conversation from speculation to objective data.
For independent practices, hospital departments, and billing companies, gastric emptying studies create two parallel challenges. Clinicians need to know when the test is appropriate and how to interpret the results in context. Revenue cycle teams must ensure correct ordering, documentation, coding, and billing, because nuclear medicine tests are frequent targets for medical necessity and technical‑component denials.
This article is written for gastroenterologists, hospital RCM leaders, and billing managers who want a practical framework for managing gastric emptying studies end to end. We will walk through clinical indications, preparation and protocol, result interpretation, and then connect all of that to documentation, coding, and denial‑prevention strategies that protect reimbursement.
1. Where Gastric Emptying Studies Fit in the Diagnostic Strategy
Gastric emptying studies are not screening tests. They are targeted tools used when you suspect a motility disorder that other modalities cannot fully characterize. Knowing where GES fits in the diagnostic sequence avoids unnecessary imaging and supports medical necessity if a payer questions the order.
Common clinical scenarios where GES adds value
- Suspected gastroparesis: Chronic nausea, vomiting of undigested food several hours after meals, early satiety, postprandial fullness, weight loss, or poorly controlled diabetes with upper GI symptoms.
- Post‑surgical symptoms: Patients after gastric bypass, sleeve gastrectomy, vagotomy, or fundoplication who develop dizziness, diarrhea, or hypoglycemia shortly after meals (concern for dumping syndrome) or persistent fullness and vomiting (possible delayed emptying).
- Refractory dyspepsia: Endoscopy and structural imaging are unrevealing, but the patient has persistent bloating and early fullness that suggest a functional or motility component.
- Therapy monitoring: Assessing response in known gastroparesis or other motility disorders after starting or changing prokinetic drugs, dietary plans, or other interventions.
Why this matters for care and revenue: When providers position GES appropriately in the workup, the test is easier to justify in documentation. That supports ICD‑10 coding that clearly ties symptoms and history to the test, which is exactly what medical necessity algorithms look for. Ordering GES as a reflex test without documenting prior negative EGD or imaging can invite denials for “insufficient conservative workup.”
Operational checklist before ordering a GES:
- Confirm that structural causes (ulcer, malignancy, obstruction) have been reasonably excluded with history, labs, and imaging where appropriate.
- Document the key symptom cluster: duration, frequency, impact on nutrition or weight, and failed therapies.
- In diabetes or post‑surgical patients, explicitly state the suspicion (for example, “suspected diabetic gastroparesis” or “rule out rapid gastric emptying after sleeve gastrectomy”).
- Ensure your order entry system maps to the correct nuclear medicine gastric emptying test and not a generic “stomach scan” code.
Done well, this early step aligns clinical rationale and claim language, reducing back‑end appeals work later.
2. Protocol, Preparation, and Workflow: Reducing Noise in the Data
From a clinical standpoint, a gastric emptying study is only as good as its protocol. From a revenue standpoint, inconsistent protocols create variability in interpretation and can be questioned by auditors. Leaders should standardize preparation and workflow across sites and clearly educate referring providers.
Standardized test design and why it matters
The most widely accepted method is solid‑meal gastric emptying scintigraphy. A typical protocol uses a standardized low‑fat egg or egg‑white meal labeled with a gamma‑emitting tracer, with imaging at defined time points (often 0, 1, 2, and 4 hours). Consistency is the key. Different meals, different imaging times, or ad‑hoc techniques make it harder to compare results to published normal ranges.
Key preparation steps and clinical rationale:
- Fasting: Usually 4 to 6 hours before the test to avoid residual food in the stomach that would falsely elevate retention values.
- Medication management: Temporarily holding prokinetic agents (for example, metoclopramide), potent anticholinergics, and opioids when clinically safe; these drugs significantly alter gastric motility.
- Glycemic control in diabetics: Marked hyperglycemia can slow gastric emptying. Addressing blood glucose helps avoid attributing drug‑ or glucose‑mediated delay to permanent motility dysfunction.
- Timing relative to barium or other nuclear studies: Recent contrast or overlapping tracers can interfere with image quality or quantification.
Operational implications:
- Create a standard patient instruction sheet co‑branded with nuclear medicine and gastroenterology leadership.
- Build pre‑test checklists into scheduling scripts and patient portals to ensure fasting and medication guidance is delivered and acknowledged.
- Use EHR prompts for referral providers to indicate medications that could affect motility and whether they should be held.
These steps not only improve clinical signal, they also protect against payers questioning abnormal studies that were done under non‑standard conditions. Internal policies that mirror published society guidelines strengthen your defensibility in appeals.
3. Interpreting Results: Translating Percent Retention into Clinical Action
The nuclear medicine report typically provides the percentage of meal retained in the stomach at several time points. Leadership should ensure that providers and coders alike understand what these numbers represent, because they affect diagnosis selection, medical necessity, and even utilization review.
Using retention thresholds meaningfully
Although exact thresholds vary slightly by protocol, many centers use approximate cutoffs similar to the following:
- At 1 hour: retention less than roughly 90 percent is generally acceptable.
- At 2 hours: retention greater than roughly 60 percent suggests delayed emptying.
- At 4 hours: retention greater than roughly 10 percent strongly supports gastroparesis.
How to integrate the numbers:
- Clinically relevant delay: Do not treat a marginally elevated 1‑hour value as definitive disease. The 4‑hour data are far more predictive of clinically important gastroparesis.
- Early rapid emptying: Very low retention early in the study in a post‑surgical patient may support dumping syndrome, especially when linked to documented postprandial tachycardia, diarrhea, or hypoglycemia.
- Discordant symptoms and results: If a patient has chronic upper GI symptoms but a normal 4‑hour study, consider functional dyspepsia, medication side effects, or small bowel issues rather than reflexively labeling gastroparesis.
Documentation points that help coding and billing:
- Explicitly state whether gastric emptying is delayed, normal, or rapid, and at which time point.
- Relate the result to the working diagnosis: for example, “Study supports diabetic gastroparesis” or “Findings consistent with rapid gastric emptying after gastric bypass.”
- When normal, explain the clinical implications, such as “Motility disorder not confirmed; symptoms likely due to functional dyspepsia,” which supports alternative ICD‑10 selection.
When the report and the clinic note tell a consistent story, coders are better positioned to select accurate ICD‑10 codes. Payers also have less room to argue that the test was non‑diagnostic or unrelated to the reported diagnoses.
4. Common Pitfalls in Ordering and Performing GES and How They Create Denials
From an RCM perspective, gastric emptying studies fail as often because of process defects as they do because of payer behavior. Understanding recurrent mistakes allows you to build guardrails around both clinical ordering and billing.
Typical failure modes
- Vague indications in orders: Orders that list “abdominal pain” without duration, associated symptoms, or failed therapy are easier for payers to question than those that document chronic nausea, vomiting, and weight loss.
- Inconsistent protocols between facilities: Different meal compositions, incomplete 4‑hour imaging, or lack of standardized time points make results harder to defend as guideline conformant.
- Poor linkage to outcomes: If the chart does not show how the study affected management, auditors may flag the test as low‑value or “not necessary for decision‑making,” particularly in repeated studies.
- Under or overuse: Ordering GES for every dyspeptic patient without excluding simpler causes first can look like overutilization. On the other hand, failing to order it in clearly indicated cases leads to prolonged care, repeat visits, and higher downstream costs.
Revenue and denial impact:
- Nuclear medicine procedures can carry substantial technical and professional charges. A single denied gastric emptying claim may represent hundreds of dollars in lost revenue and additional staff time on appeals.
- Patterns of “insufficient documentation” denials can trigger focused audits of other imaging services at the same facility.
- Repeated tests without clear intervals or rationale may be recouped in post‑payment reviews even if they were initially paid.
Mitigation framework for leadership:
- Align your local GES protocol with current nuclear medicine and gastroenterology guidelines, then save this policy as a reference for appeals.
- Implement order sets that require entry of symptom duration, diabetes status, prior upper endoscopy or imaging, and key red‑flag features.
- Flag repeat GES orders in the EHR and require a brief statement of why a second or third study is clinically necessary (for example, “assessing response to prokinetic therapy after 6 months”).
- Audit a small sample of GES charts quarterly to ensure that indications, results, and management decisions are all clearly captured.
These steps lower denial risk and also signal to payers that your organization applies appropriate utilization management internally.
5. Coding and Billing Strategy: Connecting Clinical Reality to Reimbursement
Once the study is ordered and completed appropriately, the job is only half done. Accurate coding and billing for gastric emptying studies require clear roles between the technical provider (for example, hospital imaging department or outpatient imaging center) and the professional interpreter (nuclear medicine physician or radiologist), as well as precise diagnosis coding.
CPT and component considerations
While specific code sets change periodically, there are consistent patterns that RCM leaders should manage:
- GES is coded under nuclear medicine gastrointestinal procedures. Typically, there is a CPT code that includes the imaging and data analysis associated with a solid‑meal gastric emptying test.
- In many settings, you will bill separate technical and professional components (modifier TC for technical and modifier 26 for professional) depending on who owns the equipment and who reads the study.
- If combined studies are done, such as including esophageal transit or small bowel follow‑through, ensure that the documentation supports each billed component and that bundling edits are reviewed.
ICD‑10 coding alignment
- Primary diagnosis often reflects the suspected or confirmed motility disorder, such as diabetic gastroparesis, idiopathic gastroparesis, postsurgical dumping syndrome, or other specific gastric dysmotility codes as available.
- Secondary diagnoses should capture underlying conditions like Type 1 or Type 2 diabetes with complications, prior bariatric surgery, autonomic neuropathy, or connective tissue disorders.
- When the study is normal, link ICD‑10 codes to the symptomatic indication (for example, chronic nausea and vomiting, early satiety, or dyspepsia) that justified the test.
Documentation elements that protect payment:
- Referrer note stating why GES is preferred at this stage instead of or in addition to other diagnostics.
- Nuclear medicine report that describes the meal, imaging times, and percent retention, with a clear interpretive statement.
- Follow‑up clinic note explaining how results affect therapy (new medications, dietary changes, surgical referral, or reassurance and alternative diagnosis).
For complex or high‑volume gastroenterology groups, it can be helpful to engage external coding expertise on motility procedures. One of our trusted partners, Quest National Services, focuses on full‑service medical billing and supports organizations that need deeper expertise in aligning specialty diagnostics like GES with current coding and payer policy.
6. Integrating GES into an RCM‑Aware Clinical Pathway
Gastric emptying studies bridge clinical and financial performance. The most successful organizations do not treat them as isolated tests, but instead embed them into standardized care pathways that also reflect revenue cycle considerations.
Designing a coordinated pathway
A practical approach is to map the GES lifecycle as an internal mini‑workflow:
- Step 1: Triage and indication confirmation
Front‑end staff use simple scripts to check that the presenting symptoms and prior workup match your organization’s GES criteria. Questionable cases can be routed to a clinician for approval rather than automatically scheduled. - Step 2: Preauthorization and benefit verification
Where payers require prior authorization for nuclear medicine studies, a standard packet should include your protocol summary, typical indications, and recent clinical note excerpts. Eligibility and benefit teams should confirm coverage and patient financial responsibility ahead of time to avoid write‑offs. - Step 3: Test performance quality control
Nuclear medicine technologists and nurses follow a checklist covering fasting, medications held, tracer preparation, and image timing. Deviations are recorded and communicated in the report. - Step 4: Post‑test follow‑up and documentation
Providers review results within a set timeframe and document a concrete plan, such as dietary modification, medication adjustment, or surgical referral. This strengthens the linkage between test and management. - Step 5: Coding review and denial monitoring
Coding staff have specific rules for which ICD‑10 combinations and CPT modifiers to use for GES. Denial trends for this test type are reviewed monthly. Any spike triggers a focused review of orders and documentation.
Key performance indicators (KPIs) worth tracking:
- Preauthorization approval rate and average days to approval for nuclear medicine GI procedures.
- First‑pass claim acceptance rate for gastric emptying studies.
- Denial rate and top denial reasons related to GES within 30 and 90 days of initial claim.
- Average lag between test date and signed nuclear medicine report.
- Percentage of GES results with a documented management change within 30 days.
These metrics do not just inform finance, they also help quality and clinical leadership see whether the test is being used thoughtfully and whether it is influencing patient care in the way guidelines intend.
7. Strategic Takeaways and Next Steps for Practices and RCM Leaders
Gastric emptying studies exemplify the broader challenge of specialty diagnostics in revenue cycle management. Clinically, they can end months of uncertainty by confirming or excluding motility disorders like gastroparesis or dumping syndrome. Financially, they involve higher reimbursement, complex payer rules, and risk of retrospective audit.
When organizations bring order to how they use GES, they typically see improvements in both care and cash flow. Standardized indications support medical necessity. Consistent protocols limit disputes about methodology. Strong documentation and accurate coding keep payments secure and reduce rework.
If your group is seeing repeated denials, high write‑offs, or confusion between physicians and billing teams around gastric emptying studies, this is a signal to redesign the workflow rather than simply work harder on appeals. Clinicians, nuclear medicine, and RCM staff should sit together to create shared standards, then educate front‑line staff and monitor performance.
If you are looking to complement internal efforts with outside expertise in specialty billing and denial management, working with experienced RCM professionals can be an efficient path. One of our trusted partners, Quest National Services, specializes in comprehensive medical billing and can help organizations align clinical protocols with billing requirements for tests like gastric emptying studies.
To explore how you can tighten your gastric emptying study workflow, reduce denials, and stabilize GI‑related revenue, you can also contact us. Our team works with practices, hospital departments, and billing companies to build practical, high‑yield revenue cycle improvements that reflect real clinical workflows rather than abstract policy.
References
American College of Gastroenterology. (n.d.). Guideline on the management of gastroparesis. Retrieved from https://gi.org
Abell, T. L., Camilleri, M., Donohoe, K., Hasler, W. L., Lin, H. C., Maurer, A. H., … & Ziessman, H. A. (2008). Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. Journal of Nuclear Medicine Technology, 36(1), 44–54. https://tech.snmjournals.org
MedlinePlus. (n.d.). Gastric emptying tests. U.S. National Library of Medicine. Retrieved from https://medlineplus.gov/lab-tests/gastric-emptying-tests/
