Gastroenterology Coding Alert

To claim better reimbursement, many gastroenterology practices are changing how they report some ERCP stent procedures. For stent replacements and multiple stent placements, gastroenterologists will have to determine how aggressive they want to be when billing because there are no definitive guidelines from CMS or local carriers on how these procedures should be coded. 
 
Stents can be placed during an ERCP in both the bile and pancreatic ducts. They are used to keep the ducts open and bile flowing when an obstruction, often due to cancer, threatens to close the duct, according to Sarkis J. Chobanian, MD, FACP, FACG, a gastroenterologist in Knoxville, Tenn. The stents are made of several materials. Plastic stents are usually placed temporarily, while metal mesh stents are for long-term placements. But neither the duration of the placement nor the material the stent is made of affects how a stent procedure is coded.

Three Methods for Billing Removal/Replacement

 
When the stents have to be removed and replaced because they have become occluded, there are at least three different ways to report the procedure. Coding is confusing because most gastroenterologists consider the replacement of an ERCP stent to be two procedures: the removal of the old stent (43269) and the insertion of the new stent (43268). Many gastroenterology practices have traditionally avoided reporting both codes together, because they are listed as a mutually exclusive edit in the Correct Coding Initiative (CCI). Mutually exclusive codes are those procedures that cannot reasonably be done in the same session.
 
"We would never bill for both the removal and replacement of a stent in the same session," says Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 23-physician practice. "It's a mutually exclusive coding combination, and we don't think we would ever get paid for it. Our physicians feel that there isn't any more work involved in doing a removal and replacement because the bile or pancreatic duct is still open."
 
The most conservative approach to billing a stent removal and replacement is to report only 43269, which pays $381 on an unadjusted basis when performed in a facility. Because the CPT description of this code includes the phrase "removal of foreign body and/or change of tube or stent," many gastroenterology practices feel that this code comes closest to describing the entire procedure.
 
In addition, Medicare payment rules direct carriers to reimburse the lesser-valued code, which in this situation is 43269, when two mutually exclusive edits are reported on the same claim. Some gastroenterology practices interpret this to mean that they must only report the lesser-valued code when it comes to ERCP stent removal and replacement.
 
To receive more reimbursement than they would get by just reporting 43269, some practices are opting to report the replacement only with 43268. This is how Parks bills the procedure at her practice, and she cites the fact that 43268 has a much higher relative value unit (RVU) than 43269 and pays $464 on an unadjusted basis versus $381 for 43269. 
 
In the most aggressive coding scenario, some gastroenterologists challenge the conventional wisdom and bill for both procedures. "We used to bill only for 43269 until we went to some coding seminars last spring that told us we could bill both," says Barbara Kallas, billing specialist for Gastroenterology Consultants, a practice with 10 gastroenterologists in Milwaukee. "So now we bill 43268 with modifier -59 [distinct procedural service] and then bill 43269."
 
Modifier -59 is attached not to the code with the lowest value, as some gastroenterology practices mistakenly do, but to the code that would otherwise be denied by the payer. Modifier -59 indicates that it is a distinct and separate procedure.
 
Justification for billing both codes comes from two areas. First, the 43268-43269 mutually exclusive edit in the CCI has a superscript of 1, which indicates that a modifier can be used to override the edit and differentiate between the services provided. Unfortunately, the CCI does not explain when it would be appropriate to bill both 43268 and 43269.
 
The other support for billing both codes come from the spring 1994 issue of the CPT Assistant, which states that "[if] a stent is already in place but must be replaced (perhaps because it has become occluded), 43269 is used to describe the passage of an endoscope to remove the old stent, and the above described procedure (43268) for the placement of a new stent."
 
Even this reference in the CPT Assistant doesn't convince Parks that both codes can be reported. "I wouldn't bill both codes to private payers [who might strictly follow CPT coding conventions]," she says. "Many practices will have good arguments for billing both codes. The physicians in my practice feel that reporting both might trigger an audit because you are trying to unbundle two bundled codes."

Billing for Multiple Stent Placements Is Changing

 
Another area of controversy is whether to report multiple stent placements during the same session. "Stents can be placed in both the bile and pancreatic ducts during the same session," Chobanian says. "You can also insert more than one stent at a time in the bile duct. Typically only one stent will be inserted in the pancreas, but it is possible to insert more than one."
 
The traditional view is that the stent placement (43268) can be reported only once, regardless of how many stents are placed during the session. "We would never bill for more than one stent placement," Kallas says. She adds that this approach is in keeping with the coding convention for many procedures in gastroenterology such as polypectomies and biopsies where only one code is reported no matter how many are performed.
 
Parks' practice, however, has recently changed its billing policy for multiple stent placements and now will bill code 43268 twice if they are done in both the bile and pancreatic ducts. Modifier -59 is added to one of the codes to indicate that these are separate and distinct sites. If two stents are placed in the same duct, they report the code only once on the claim.
 
"The CPT description does not specify multiple stents, and we are trying to code according to what the gastroenterologist did," Parks says. "You are not likely to get paid for both because it is the same procedure performed twice on the same day of service in the same operative setting, however. We just got a denial for a claim where we billed two stent placements, but we will not trigger an audit even though we were denied because these are not bundled codes."
 
Parks says they plan to appeal these denials, and she hopes that eventually they will start to see some additional reimbursement for these multiple placements.

Stent Placements as Part of a Coding Combination

 
Coding questions also occur when a stent placement is one of many procedures performed during a single ERCP session. It would not be uncommon, for example, to have an ERCP with a stent placement (43268), papillotomy (43262), mechanical lithotripsy (43265), balloon dilation of stricture (43271) and stone removal (43264) all in a single session. Because none of these codes are bundled together in the CCI, they are separately reportable, Parks says. She recommends arranging the codes in descending order according to their RVUs, which is as follows: 43264, 43265, 43268, 43262 and 43271. Modifier -59 should be attached to all the codes except the first one, to indicate that these are distinct and separate procedures.
 
The number of procedures that will be reimbursed in the above example varies by payer, Parks says. The highest-valued procedure (43264) should be reimbursed at 100 percent of its allowable fee. The second and third highest-valued procedures (43265 and 43268) should be reimbursed according to the multiple-endoscopy payment rules because all of these procedures have the same base endoscopic code (43260), and reimbursement should be the difference between the allowable fees for these codes and the base endoscopic code.
 
While some payers may not reimburse for anything beyond the third procedure, Parks believes that those should be reported because some payers will cover them. And there is no penalty for reporting them and being denied because they are not bundled codes.