Gastroenterology Coding Alert

One of the golden rules of coding for gastroenterology used to be that an endoscopic retrograde cholangiopancreatography (ERCP) and an upper gastrointestinal endoscopy (EGD) performed during the same session could not be billed separately because they were bundled together in the Correct Coding Initiative (CCI) edits. While Medicare has removed many of these ERCP-EGD edits, some gastroenterology practices are losing reimbursement by continuing to bill these procedures as if the edits still exist. Even ERCP-EGD combinations that are still bundled together in the CCI may be overridden with the proper modifier if the two procedures are separate and distinct.
 
"I was always told to never bill an ERCP and EGD procedure together because they were bundled," says Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 23-physician practice. "But if you look at the CCI edits, some of those have been changed."

 
Coders must understand the differences between these two endoscopic procedures, which both involve passing a scope through the esophagus to the duodenum, to code them appropriately. An EGD is done to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting or difficulty swallowing. It detects upper gastrointestinal bleeding, ulcers and strictures.
 
An ERCP, on the other hand, is for a different set of medical indications. The procedure evaluates and visualizes the hepatobiliary system, which includes the pancreatic ducts, hepatic ducts, common bile ducts, duodenal papilla (also known as the ampulla of Vater) and the gallbladder. A side-viewing endoscope (also referred to as a duodenoscope) is passed orally into the duodenum, where a cannula or hollow tube is inserted into the major papilla and injected with contrast material that allows the gastroenterologist to see the entire hepatobiliary system with the aid of a fluoroscope.
 
ERCPs are commonly used to investigate elevated liver lab tests and to diagnose and treat conditions of the bile duct and pancreas including gallstones, sclerosing cholangitis, and pancreatic cancer, says Sarkis J. Chobanian, MD, FACP, FACG, a gastroenterologist in Knoxville, Tenn.
 
Another way to distinguish between the two procedures is through the different scopes that are used for each. For an EGD, the gastroenterologist will use a traditional endoscope -- a long, thin, flexible tube with a tiny video camera and light at the end. During an ERCP, the side-viewing duodenoscope will be used. The two scopes are not interchangeable in terms of function because even though it passes through the esophagus, the duodenoscope doesn't give the gastroenterologist a good view of the esophagus, Chobanian says.
 
One of the most common ERCP-EGD coding combinations is an ERCP procedure performed during the same session as an EGD with biopsy. "A patient may have the symptoms of an ulcer and at the same time have indications of stones," Chobanian explains. Separate scopes must be used to evaluate each set of symptoms.

 
An ERCP with the removal of stones (43264) and an EGD with biopsy (43239) can be billed separately because they are no longer bundled in the CCI edits, says Parks, who would attach modifier -59 (distinct procedural service) to 43239 to indicate that they were separate procedures. Payment should be 100 percent of the allowable fee for 43264, which is about $549 on an unadjusted basis. Because 43239 is from a different endoscopic family, the standard payment rules for multiple surgeries apply for this procedure, and payment should be 50 percent of the allowable fee or about $88 on an unadjusted basis.
 
Gastroenterology practices that continue to bill the procedures as if they were bundled are losing close to $70 in reimbursement on the EGD with biopsy. When 43264 and 43239 were bundled together, gastroenterologists used to report an ERCP with biopsy (43261) instead of the EGD with biopsy and received less reimbursement. The payment for 43264 would still be 100 percent of the allowable fee. Because 43261 is from the same endoscopic family as 43264, the standard payment rules for multiple endoscopies would apply. Payment for 43261 would be about $16 in this situation or the difference between the allowable fee for 43261 and the allowable fee for its endoscopic base code, 43260 (diagnostic ERCP).

 
Not all of the ERCP-EGD edits have been removed, which may cause some coding confusion. The diagnostic ERCP (43260) and an EGD with biopsy (43239) are still bundled together. Also, an ERCP with biopsy (43261) and EGD with biopsy (43239) remain bundled together.
 
When these codes are bundled, many practices will only bill for the ERCP, which is the higher-valued service. "We don't bill for both even if we do both," says Barbara Kallas, billing specialist for Gastroenterology Consultants, a practice with 10 gastroenterologists in Milwaukee.
 
When the patient has one set of symptoms or indications, Parks would also bill only one code. "If the patient is having upper abdominal pain, the gastroenterologist may do a diagnostic ERCP (43260) if a diagnostic EGD (43235) doesn't reveal what the cause is," she explains. "We would only bill for the EGD if a biopsy were performed; we wouldn't bill separately for just the diagnostic procedure."

 
While some practices may choose not to bill for both procedures, it is possible to bill for both under certain circumstances -- even though they are bundled. Because the CCI edits for ERCP-EGD combinations have an indicator (or superscript) of 1, these edits can be overridden with a modifier, usually modifier -59, when the procedures are separate and distinct. The different scopes used during the two procedures determine when it is appropriate to override the ERCP-EGD edit. If the side-viewing duodenoscope and the traditional endoscope where used during the same session, then two separate procedures have been performed, and gastroenterologists can report both procedures by adding modifier -59 to the EGD procedure.
 
However, gastroenterology practices need to guard against upcoding to the higher-paying ERCP-EGD-with-biopsy combination when they performed ERCP with biopsy, Parks says. For example, if a gastroenterologist performs biopsies in the stomach using the side-viewing duodenoscope, the procedure should be reported as an ERCP with biopsy even though biopsies of the stomach are traditionally performed with an EGD scope.

 
Other EGD procedures besides EGD with biopsy can be performed in combination with an ERCP, such as an EGD with dilation. For example, a gastroenterologist may perform an EGD with balloon dilation (43249) and then an ERCP with a sphincterotomy (43262) in the same session. Code 43262 should be listed first on the claim and will be reimbursed at 100 percent of its allowable fee. Code 43249 should have modifier -59 attached to indicate that it was a separate procedure, and payment for this code should be 50 percent of its allowable fee under the multiple-surgeries payment rules.

 
Not all payers will reimburse for an ERCP-EGD combination, even when the codes are not bundled. "This is especially true if it's a private payer," Parks says. Attaching an operative report to all ERCP-EGD claims might increase the odds of getting reimbursed, Kallas believes. "We always send the operative reports when we are billing both procedures because we hope that it will speed up reimbursement," she says. "The claim may still be denied, but at least the payer has all the paperwork in front of them."