Gastroenterology Coding Alert

You don't have to feel overwhelmed when you receive a procedure note detailing a stent and stone removal. Perfect your strategies using this scenario, and you'll breathe easier in the future.

Procedure: Endoscopic retrograde cholangiopancreatography with stent and stone removal.

Indications: The patient with known choledocholithiases, status post cholecystectomy. About five weeks ago, the patient underwent a stent placement in the biliary tract, at the request of surgery, as a guidewire purposefully made her cystic duct closure loose.

Postprocedure diagnosis:

1. Biliary stent removed.

2. Cholangiogram revealing two small remaining common bile duct stones, 3 mm each. I removed both with balloon sweep.

3. Post balloon occlusive cholangiogram normal.

Preoperative medications: Fentanyl 200 mcg IV, Versed 7 mg IV.

Complications: None.

Findings: After I obtained informed consent, the patient got into prone position. I placed the video side-viewing duodenoscope under indirect visualization and advanced. The stomach and duodenum were normal. I saw a biliary stent exiting the ampulla. I used a snare to grasp this and remove it from the patient. I reintroduced the upper endoscope under indirect visualization and advanced to the ampulla. The ampulla was status post sphincterotomy. Using a balloon catheter and a wire, I was able to cannulate the common bile duct. Balloon occlusive cholangiogram revealed two small filling defects.

I performed a balloon sweep with a 15-mm balloon, and I removed both filling defects. Then I performed a repeat balloon occlusive cholangiogram, which was normal. Finally, I did one further balloon sweep with a 15-mm balloon with no stones or debris exiting the ampulla.

Impressions: Removed stent, as above. Removed two small common bile duct stones, as above. Post balloon occlusive cholangiogram was normal. The final 15-mm balloon sweep was also normal, without removal of any further stones or debris.

Plan: I will have my nurse contact the patient, obtain repeat liver tests in about three weeks to make sure they normalize. Otherwise, the patient requires no further management. She will follow up with her primary-care physician (PCP).

Have your codes in hand? Check them against our experts' answers.

CPT: You noticed the physician removed a stent. For that service, you'll rely on 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent).

Second, the physician removed two common bile duct stones. To report this procedure, you should use 43264 (... with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts).

Did you know? "Even if the gastroenterologist doesn't see any actual debris with the balloon sweep, you should still report 43264," says Susan Williams, CPC, CGCS, coder at Austin Gastroenterology PA in Texas.

ICD-9: For the diagnosis, you should use 574.51 (Calculus of bile duct without mention of cholecystitis; with obstruction) for both procedures (43269 and 43264). You can also use V53.99 (Fitting and adjustment of other device) to help substantiate the stent removal (43269).

Your claim should look like this:

• 43264 linked to 574.51

• 43269 linked to 574.51, V53.99.

Note: In general, most practices elect to list the higher valued code first, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. Code 43264 has a relative value unit of 4.44, while 43269 has 4.1 RVUs; therefore, you should list 43264 first.