Gastroenterology Coding Alert

Get paid twice the $440 rate for 43268. Find out how.

If you think coding for endoscopic retrograde cholangiopancreatography (ERCP) is a simple one-code affair, you're mistaken. If your gastroenterologist performs a sphincterotomy, gallstone lithotripsy, stent placement, or a fluoroscopy, you can mix and match the different ERCP CPTs without any consequences -- except, perhaps, a much welcome added dollars to your reimbursement.

Read through the following 3 frequently asked questions and get no-nonsense advice straight from the experts.

FAQ 1: Should I Mind 43268, 43262 Bundles?

When your gastroenterologist performs a pancreatic stent placement during an ERCP with sphincterotomy, you can bill for two CPTs on your claim: 43268 (Endoscopic retrograde cholangiopancreatography; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) in addition to 43262 (Endoscopic retrograde cholangiopancreatography; with sphincterotomy/papillotomy).

And you don't have to worry about using any modifier as no such is required, according to Jennifer Lawrence, CPC, patient accounts manager at Westside Gastroenterologists, Inc. in Middleburg Heights, Ohio.

In fact, CPT allows you to report both procedures, based on 43268's parenthetical instruction which states, "When [43268 is] done with sphincterotomy, also use 43262." If you billed two or more allowed ERCP codes, then you get paid the highest valued code at 100 percent, and at the full rate MINUS the base ERCP reimbursement rate with the other codes.

Each forgotten code would cost a couple of hundred dollars depending on the carrier.

General rule: Medicare and other private payers bundle the stent placement (43268) into the removal (43269, ...with endoscopic retrograde removal of foreign body and/or change of tube or stent). This means you won't get paid separately for the placement of a stent when a prior stent was removed at the same session. However, you can try your luck with some thirdparty payers, which may have no policy against billing for both stent placement and removal.

FAQ 2: What About Fluoroscopy and Reporting 43268 Twice?

You can bill 43268 multiple times, but only if the gastroenterologist performs an ERCP and places stents in multiple ducts. That's more than a $100 payment per additional stent based on national average.

Example: Your gastroenterologist places multiple pancreatic stents during an ERCP. You would report 43262, and 43268 twice.

Meanwhile, fluoro procedures 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) and 76001 (Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]) are bundled into diagnostic ERCP.

In 2003, Correct Coding Initiative (CCI) released an official guideline making 76000-76001 components of 43260-43272.

FAQ 3: Does ERCP With Radiologic Supervision and Interpretation Exist?

Yes. In fact, in some situations you can report this procedure using 74328 (Endoscopic catheterization of biliary ductal system, radiological supervision and interpretation), 74329 (Endoscopic catheterization of the pancreatic ductal system ...), or 74330 (Combined endoscopic catheterization of the biliary and pancreatic ductal systems ...). Both 74328 and 74329 reimburse about $37 (0.7 RVU multiplied by 36.8729 2010 conversion factor), while 74330 pays about $47 (0.9 RVU multiplied by 36.8729 2010 conversion factor).

Before you bill radiologic supervision and interpretation, make sure to double check these items:

The gastroenterologist must indicate in his notes that he supervised the ERCP, and he must also complete a separate note for his radiologic interpretation of the procedure x-ray images.

The service is reportable only one time. In hospital settings, the radiologist may report 74328-74330 ahead of the gastroenterologist. In this case, the physician is barred from reporting the codes even if she prepares a separate report.

You should append modifier 26 (Professional component) to 74328-74330, as appropriate, if the gastroenterologist provides the service in a facility setting.