Introduction: A wireless pH capsule study with a composite score is a reliable method to quantify acid exposure in the distal esophagus. The optimal cut-off value for pathological acid exposure time is not standardized and ranges from 4.4% - 5.8% in different studies. We evaluated the reflux burden and symptom association of patients when the threshold for acid exposure time (AET) is varied from 4% to 6%. Methods: All 96-hour wireless pH capsule studies in our urban, academic gastroenterology practice between January 2016 and December 2017 were analyzed using AET greater than 4%, 5%, and 6% as the threshold for abnormal acid reflux to evaluate the differential yield of pathologic acid exposure with these alternative thresholds. All antacids or acid suppression medications were held for at least 7 days prior to the examinations. Results: A total of 257 consecutive patients (94 male, mean age 52.6 years (19-84 years) were included for analysis. Using the 4%, 5%, and 6% threshold values for overall AET; 19.8% (51), 27.6% (71), and 33% (85) patients did not have evidence of abnormal acid reflux respectively, over a 96-hour period. The evaluation of the 34 patients who were “missed” by increasing the AET from 4% to 6% showed: Median symptom association probability (SAP) for heartburn and regurgitation was 98.6 (IQR 84.3) and 72.4 (IQR 97.3), respectively. The median symptom index (SI) for heartburn and regurgitation was 26.8 (IQR 37) and 12.3 (IQR 25.7) respectively and the mean DeMeester score was 19.5 (range: 12.9 - 27). At 5% threshold value (14 out of 34 missed patients), SAP was positive (>95%) in 8 and 4 patients for heartburn and regurgitation respectively. The SI was positive (>50%) in 1 patient for heartburn and none for regurgitation. At 4% threshold value for AET (20 out of 34 missed patients), SAP was positive in 12 and 5 patients for heartburn and regurgitation respectively. The SI was positive in 3 patients for heartburn and 3 patients regurgitation. Conclusion: Increasing the percent AET from 4% to 6% reduces the identification of pathologic acid reflux by 14%. Using 6% as the AET threshold primarily reduces the identification of positive SAP and SI for heartburn and regurgitation symptoms to acid reflux. Patients in this group may represent a subgroup of reflux patients that specific targeted therapies may improve therapeutic outcomes and warrants further study.