Gastroenterology Coding Alert

Hint: Don’t forget to report other procedures performed such as stone or debris removal.

When you apply the new ERCP codes for stent placements and removal/replacement, you’ll base your reporting on the number of stents that your clinician placed or replaced while remembering that any sphincterotomy or dilation performed concurrently is included in the new codes.

If your gastroenterologist places a stent by performing an ERCP in the biliary or pancreatic ducts, report this procedure with 43274 (Endoscopic retrograde cholangiopancreatography [ERCP]; with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent).

This new code that you will begin using after Jan.1, 2014 will replace the CPT® code 43268 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct).

New way: When you report43274 for stent placements, you’ll not have to report a sphincterotomy separately as you had to do when you were using 43268. As you can see from the descriptor to 43274, this code is comprehensive and includes the sphincterotomy that was performed prior to placement of the stent.

Old way: Prior to 2014, , you reported 43262 (…with sphincterotomy/papillotomy) along with 43268 if your clinician performed a sphincterotomy prior to placement of the stent.

Another change: Unlike the old code sets, you do not have to report any dilation performed by your gastroenterologist prior to placement of the stent using the new CPT® code 43277 (…with trans-endoscopic balloon dilation of biliary/pancreatic duct[s] or of ampulla [sphincteroplasty], including sphincterotomy, when performed, each duct), as this part of the procedure is also included within the work described by 43274.

Report 43274 for Each Stent Placed

When your clinician performs an ERCP and places a stent, you report it with 43274 when the date of service is after Jan.1, 2014. When your clinician places more than one stent, you have to report each placement of the stent with one unit of 43274. If you look at the descriptor of 43274, it clearly mentions the phrase “each stent” which means that you have to report one unit of the code for every stent placed. This is again a change from the old way of reporting stent placements.

Don’t forget: Append modifier 59 to 43274 for additional stent placements.

Old way: When you would report 43268 for placement of the stent, you would only report it once for the placement of the stent(s) in one duct. For example, if your clinician would place multiple stents within the biliary duct, you would only report 43268 once. You would report 43268 and 43268-59 (Distinct procedural service) if your clinician would place stents in both the biliary and pancreatic ducts.

Example: Your gastroenterologist assesses a 53-year-old male patient who came to your clinician with complaints of abdominal pain (described as dull and steady), nausea, vomiting and diarrhea. The patient complained that the pain started after a party two days prior where he went on an alcohol binge. Your clinician also noted history of biliary colic and a history of alcohol use from past 15 years.

Upon physical examination, your gastroenterologist noted left and right upper abdominal tenderness, distension, fever and some signs of jaundice. Suspecting biliary pancreatitis your clinician orders tests and an abdominal CT. Your gastroenterologist performs an ERCP and places a stent in the pancreatic duct. He performs a sphincterotomy and examines the biliary duct, performs lithotripsy for destruction of a stone that is occluding the duct, and places two stents in the biliary duct.

What to report: If the date of service is after Jan.1, 2014, you report the placement of the stent in the biliary duct with 43274 x 2 and the placement of the stent in the pancreatic duct with another unit of 43274. Append modifier 59 for additional units of 43274 claimed. Since sphincterotomy is included in the work described by 43274, you’ll not report it separately. You report the destruction of the stone with 43265 (…with destruction, of calculi, any method [e.g., mechanical, electrohydraulic, lithotripsy]). Provide documentation to inform the payer that your clinician placed two stents in the biliary ducts and one in the pancreatic duct.

Avoid Coding Confusion With Distinct Codes For Removal & Replacement

The new codes sets for ERCP provide you with two distinct codes when your clinician removes or replaces a stent. “The benefit is that the new codes will help you avoid the coding confusion of picking between one code for the replacement or two codes (one for the removal and another for the insertion),” says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT® Advisory Panel. So, depending on whether your clinician performed a removal or a replacement of the stent previously inserted, you have to use these two CPT® codes to report the procedure:

• 43275 (…with removal of foreign body[s] or stent[s] from biliary/pancreatic duct[s])
  
• 43276 (…with removal and exchange of stent[s], biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged)
  

Reminder: When your clinician is only removing the stent placed, you will only use one unit of the code, regardless of the number of stents that your clinician removed during the procedure from either of the biliary or pancreatic ducts. However, if your clinician is replacing the stent by removing the old one and inserting a new one, you will have to report one unit of 43276 for each stent that is exchanged.

Again, as in the case of insertion of the stent, code 43276 for stent placement is comprehensive and includes any dilation and sphincterotomy performed. These procedures should not be reported separately using additional CPT® codes.

Example: In the example mentioned previously, if the patient were to come back to your gastroenterologist after a period of about two months with complaints of increasing pain and increasing signs of recurrent jaundice, your gastroenterologist will perform a second ERCP procedure to check for signs of occlusion of the stent.

During the procedure, your clinician observes blockage of one of the stents that had been placed previously and removes the stent with a snare and then replaces it with another stent. He also observes the pancreatic stent but leaves it in place. In such a case, you report the replacement of the biliary stent with 43276. If he were to only remove the stent and not replace it with another stent, you report 43275.