Gastroenterology Coding Alert

Intent and method guide you to appropriate codes.

When your gastroenterologist performs an endoscopic retrograde cholangiopancreatography (ERCP), you'll definitely report accurate codes if you observe specifically the reason and method used for the procedure. This coding refresher will help point you in the right direction.

Check Reason for the Procedure

Your gastroenterologist can perform an ERCP procedure with diagnostic or therapeutic intent. "A typical scenario for an ERCP is that the patient has continued epigastric pain in the ER, as an inpatient, or as an observation patient. A CT scan is done which is abnormal. Because of the abnormal CT, our physicians will perform an esophagogastroduodenoscopy (EGD) for the epigastric pain, then an ERCP for the abnormal CT," says Heather Copen, RHIT, CCS-P, Financial Advocate-Goshen OB/GYN and Goshen GI, IU Health-Goshen Physicians, Goshen, Indiana.

Over the past decade or more, other low-risk or risk-free procedures have entered the field such as endoscopic ultrasound and magnetic resonance cholangiopancreatography that have decreased the use of ERCP for strictly diagnostic purposes. "We never do ERCPs for screening procedures," adds Copen.

ERCP is carried out with therapeutic intent for the following reasons:

• Removal or destruction of stones in the biliary or the pancreatic ducts;
• For the placement/removal of stents;
• For conducting a sphincterotomy; and
• For investigating the cause of dilation of the biliary or pancreatic ducts.

Although your gastroenterologist might perform an ERCP with therapeutic intent for some particular reason, it is quite common to see the procedure being conducted for more than one reason.

For example, along with the intent of removal of a stone in the biliary duct, your gastroenterologist might also place a stent. For this reason, it is necessary to scan the operative procedure in detail to figure out all the procedures that have been performed or you may risk losing reimbursement for additional work.

If Stent is the Intent: What to Do

If your gastroenterologist performs an ERCP for the placement of a stent, then you will often see the procedure performed with a sphincterotomy in addition to the stent placement.

You would report it with 43268 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct). Sometimes, your gastroenterologist might place more than one stent. If the stents are placed in the same duct, then you report the procedure with 43268. But if the stents are placed in different ducts, you can report the second stent by using 43268 twice. If multiple stents are placed, you can use the modifier 59 (Distinct procedural service) for your claims.

Example: If your gastroenterologist placed two stents in the biliary duct and another in the pancreatic duct, then you report the procedure with the CPT® codes 43268 and 43268-59. Provide adequate documentation to inform the payer where the stents were placed to support your claim.

If your gastroenterologist is first removing a previously placed stent and then inserting another stent in its place, you report the procedure with 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent) and then with 43268. Carefully read through the procedure note to ascertain where the stent is being removed and where is it being placed.

"When a stent is removed and replaced in the same duct, then only the 43269 would be reported. If a stent is removed from the pancreatic duct but then a stent was placed in the common bile duct, you would report 43268 with a -59 modifier," says Copen. She further shares what she does. "I put a note on the claim that states that the 43269 was the pancreatic duct and the 43268 was the common bile duct. If one stent is placed in the common bile duct and one placed in the pancreatic duct, I report the 43268 twice. The second 43268 gets a -59 modifier and again I note that one is the common bile duct and the other is the pancreatic duct. This is allowable because the wording for the CPT® codes states bile or pancreatic duct, not both, so when a physician does both stents, then they are billable separately."

Look for Method in Stone Removal

When your gastroenterologist is performing a stone removal through ERCP, you report the procedure with 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts). The code remains the same irrespective of whether a balloon or a basket is used to remove the stone. "The CPT® code 43264 states that it is a removal of calculus/calculi from bilary and/or pancreatic duct. The code is also used for stone removal with balloon because a removal is a removal, no matter how it is removed," says Copen.

Warning: Stone removal with balloons should not be confused with dilation using balloons to relieve strictures that are reported with 43271 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct[s]). A stone removal with balloon should be reported with 43264. "The CPT® code 43271 specifies that it is a balloon dilation of the ampulla, biliary, and/or pancreatic duct(s) which would make this code unsuitable to use for removal of a stone with a balloon. The balloon dilation would be used if there was a stricture or stenosis of the ampulla, biliary, and/or pancreatic duct," says Copen.

If your gastroenterologist is destroying the stone with lithotripsy, you report the procedure with 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method).

Coding Tips: If your gastroenterologist performs a removal procedure with a basket or balloon and a lithotripsy in the same session, it is quite common to assume that these two procedures are mutually exclusive and cannot be reported together.

However, you should note that CPT® allows you to report both the procedures. As per multiple procedure payment reduction policy, you need to report 43265 first as this is of higher RVU value and you get a total claim. 43264 should be reported with modifier 51 (Multiple procedures), depending on payer's preference, for consideration of both the claims.

Don't Miss These Additional Procedures

Sometimes, your gastroenterologist will perform additional procedures such as a sphincterotomy along with stone removal. When your gastroenterologist needs to gain access to the bile duct or pancreatic duct, it is often necessary to cut the major papilla orifice with a wire. This is sphincterotomy or papillotomy and is a separate service not included in the other ERCP therapeutic codes.

In such a scenario, you need to report the primary procedure of the removal and then report sphincterotomy as a separate procedure with 43262 (Endoscopic retrograde cholangiopancreatography [ERCP]; with sphincterotomy/papillotomy). "If a sphincterotomy is performed with a stone removal and a stent placement then the three different codes are billable," says Copen. "When multiple sphincterotomies are performed at the same session than only one code would be allowed." This can occur when your gastroenterologist needs to gain access to both the major papilla and the nearby minor papilla.

If multiple sphincterotomies have been performed, you report the procedures using 43262 with modifier 59 (Distinct procedural service). Additionally, if your gastroenterologist took long at a difficult procedure which required multiple sphincterotomies in a single session, you append modifier 22 (Increased procedural service). "If the sphincterotomy is performed multiple times during the same session, then I would suggest putting a -22 modifier with the stipulation that the doctor documented the difficult procedure and the need to perform it multiple times," says Copen.

During the ERCP, your gastroenterologist might use a tiny camera to visualize the bile duct or the pancreatic ducts. In such a circumstance, CPT® allows the use of an additional code and you report it with +43273 (Endoscopic cannulation of papilla with direct visualization of common bile duct[s] and/or pancreatic duct[s] [List separately in addition to code[s] for primary procedure]). You need to use this code if you see that your gastroenterologist performed a cannulation to view the ducts. The tiny camera device will often be referred to as a "Spyglass™" catheter.