Gastroenterology Coding Alert

Choose wisely from 43264, 43262, and 43277 for your bile duct procedures.

Are you confused about which Endoscopic Retrograde Cholangiopancreatography (ERCP) codes to report for services including bile stone removal or sphincteroplasty? Essential: Report all the services your provider performed or put your payment at risk.

What is ECRP? ECRP is a procedure where the provider examines the ducts that drain the liver and pancreas secretions into the intestine; using a scope or fluoroscopy. The patient may need an ECRP procedure for investigation, diagnosis, and treatment of choledocholitiasis or bile stones, tumors, strictures or narrowing in the bile or pancreatic ducts, pancreatic cysts, pancreatitis, and necrosis.

Gastroenterologists may perform therapeutic ECRP procedures such as removal of the stones, lithotripsy, and relieving obstruction of the bile ducts. “A number of changes have occurred in this family of [procedure] codes over the past few years,” says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel. “The diagnosis codes have also changed.”

With a multitude of procedures and code options, you cannot afford to let your guard down as far as accuracy is concerned, says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ.

Here is an overview of the treatment options, and how to tackle coding conundrums in each case.

Choose Your Codes Carefully For Stone Removal

If your provider removes stones from the pancreatic or biliary duct, you may use the CPT® code 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with removal of calculi/debris from biliary/pancreatic duct[s]).

The procedure: The provider passes a catheter with a basket over a guide wire into the duct and the basket traps the stone. The provider then withdraws the catheter into the duodenum and lets it loose. He may also pass a balloon over a guidewire to dredge out the stones.  

Remember: The number of stones your provider removed does not matter here. You can report 43264 only once, regardless of number of stones. You will also code the procedure once even if your provider used multiple methods in the same session for stone removal.

Caveat: However, you may not report 43264 if your provider ended up not identifying any calculi or debris even if he deployed a balloon catheter for that purpose.

Know when not to report 43264: According to AMA, you should not report43264 in conjunction with:

• 43260 (Endoscopic retrograde cholangiopancreatography [ERCP]; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) or
• 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with destruction of calculi, any method [eg, mechanical, electrohydraulic, lithotripsy]).

How to Tackle ECRP with Additional Sphincterotomy

Additional sphincterotomy means cutting a portion of a ring like muscle of the bile duct to correct duct blockage. If your provider had to perform a sphincterotomy during the ECRP, you may report 43262 (Endoscopic retrograde cholangiopancreatography [ERCP]; with sphincterotomy/papillotomy).

You may report the following CPT^® codes with 43262 when your provider performs a sphincterotomy in addition to these procedures:

• 43261 (Endoscopic retrograde cholangiopancreatography [ERCP]; with biopsy, single or multiple)
• 43263 (…with pressure measurement of sphincter of Oddi)
• 43264
• 43265
• 43275 (…with removal of foreign body[s] or stent[s] from biliary/pancreatic duct[s])
• 43278 (…with ablation of tumor[s], polyp[s], or other lesion[s], including pre- and post-dilation and guide wire passage, when performed])

Beware of the bundles: If your provider places or removes stents in the biliary or pancreatic duct, sphincterotomy is included within the procedure. So remember not to report 43262 in conjunction 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)  

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)

Distinguish sphincteroplasty from sphincterotomy: Sphincteroplasty means enlarging a blocked duct or the sphincter using endoscopic balloon dilation. Dilation of the ampulla, biliary or pancreatic ducts, is a separate procedure with a CPT^® code 43277 (Endoscopic retrograde cholangiopancreatography [ERCP]; with trans-endoscopic balloon dilation of biliary/pancreatic duct[s] or of ampulla [sphincteroplasty], including sphincterotomy, when performed, each duct). You can report code 43277 for a sphincteroplasty or dilation of a ductal stricture.

Lithotripsy is Bundled with ERCP

The gastroenterologist may use lithotripsy to crush and then remove the stone fragments. In this procedure, he inserts a catheter with a wire basket directly into the duct to capture and crush the stones. You may report lithotripsy with CPT^® code 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with destruction of calculi; any method [eg, mechanical, electrohydaulic, lithotripsy]).

Important: Removal and destruction of stones are bundled. This means that if your provider first destroyed and then removed the stones, you cannot use 43265 to report the destruction of stones along with 43264 for removal, because 43265 includes removal of calculi/debris from duct(s). So you should only report 43265 once, regardless of the number of stones destroyed or methods your gastroenterologist uses.

If your provider resorted to Extracorporeal Shock Wave Lithotripsy (ESWL) to defragment the stones, you may use 47999 (Unlisted procedure, biliary tract) to report lithotripsy as a separate procedure. Because this is an unlisted procedure code, make sure to back up the claim with a copy of the operative report and a detailed description of the procedure.

Use Modifiers 51 and 59 Carefully

In general, you may go by the multiple endoscopies rule, where carriers pay for the higher valued procedure of the same family of codes at 100 percent, and pay for the difference for the second procedure. This may apply when reporting bundled codes because they have the same base endoscopic code 43260.

In some cases, you can use a modifier to claim for a distinct procedure by billing the primary code first and the secondary code with modifier 59 (Distinct procedural service).

Example: Suppose the provider places one stent in the common bile duct extending into the left hepatic duct, and another stent again in the CBD extending into the right hepatic duct within the same session, you may report 43274 twice, one for each stent placed, using modifier 59 to state that the two stents placements involved distinct procedural service.

For multiple allowed procedures, you can use modifier 51 (Multiple procedures) provided they are not bundled. However, most carriers will adjust payments for multiple procedures automatically and do not require the modifier.

If the provider took longer than usual to remove a stone during an ECRP procedure, you may append modifier 22 (Increased procedural services) for additional payment from the carrier.

Final takeaway: “Your physician probably performs these procedures in the hospital endoscopy suite and uses a paper superbill to report to you which procedures were completed and which diagnosis codes to apply,’ says Weinstein. “If you have not updated your paper superbill recently then we strongly suggest you look at the ERCP codes on your form and compare them to the recent listings.”