Gastroenterology Coding Alert

If you’re relying only on modifiers 51 and 59, you could be missing out.

If you’re overlooking reporting all the services performed while extracting stones during an endoscopic retrograde cholangiopancreatography (ERCP), then you could be leaving precious reimbursement dollars on the table. You might be falling prey to ambiguity involving the national Correct Coding Initiative (CCI) and whether you should consider some services, such as fluoroscopy or cholangiograms, provided along with ERCP as integral part of the extraction. 

Clear up this confusion by busting these myths.

Background: ERCP is a procedure using endoscopy and fluoroscopy, to visualize, examine and diagnose stones, tumors, or narrowing in the bile or pancreatic ducts. Gastroenterologists conduct this procedure under intravenous sedation, usually without general anesthesia. Frequently, therapeutic measures can be performed at the time of ERCP to remove the stones or to relieve obstruction of the bile ducts.

Myth 1: Number of Stones Decides Number of Codes 

For removal of stones, you use the code 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with removal of calculi/debris from biliary/pancreatic duct[s]) often in conjunction with the code 43262 (Endoscopic retrograde cholangiopancreatography [ERCP]; with sphincterotomy/papillotomy). Two commonly used devices for stone removal are a basket and a balloon. A catheter with a basket is passed over a guide wire into the duct and the basket traps the stone, which is then withdrawn into the duodenum and let loose. A balloon also can be used to dredge out the stones. 

Watch out: The main mistake to avoid is to code for multiple stones. The CPT® definition of 43264 says “debris/calculi,” so it doesn’t matter about the number of stones removed. You will also code the procedure once even if multiple methods are used in the same session for stone removal. 

However, there’s a catch. Although you can report the use of a balloon to remove stones, you should not confuse that with the balloon dilation of the ampulla, biliary or pancreatic ducts, which is a separate procedure reported with a new 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). As per CPT® 2014 updates, although you cannot report 43277 for use of a balloon catheter to clear stones/debris from a duct, you can report code 43277 if sphincteroplasty or dilation of a ductal stricture is required before proceeding to remove stones/debris from the duct during the same session. Earlier, the same dilation was reported with 43271, which has been deleted. So, if the GI has encountered a stricture of one of the ducts and used a balloon for ductal dilation, you can report the procedure separately. 

Myth 3: Lithotripsy is Always Bundled With ERCP

The gastroenterologist may use lithotripsy to crush and destroy the stones. CPT® 2014 updates specified that removal and destruction are now bundled and cannot be reported separately. That effectively means you cannot use the lithotripsy code 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with destruction of calculi; any method [eg, mechanical, electrohydaulic, lithotripsy]) to report the destruction of stones when performed in conjunction with 43264. This year onward, 43265 includes removal of calculi/debris from duct(s) as described by 43264. As with the stone removal, you should only report 43265 once, regardless of the number of stones destroyed or methods your gastroenterologist uses. The most commonly used method for stone destruction is mechanical lithotripsy, in which a catheter with a wire basket is inserted directly into the duct to crush the stones. 

However, sometimes the duct may be too narrow for removal of all stones or the patient is not a good candidate for a prolonged surgical or ERCP procedure. In such cases, the GI may go for another method known as extracorporeal shock wave lithotripsy (ESWL), a non-invasive procedure where acoustic shock waves administered outside of the body are focused onto the stone(s), causing them to fragment. ESWL may be preceded by endoscopic pancreatic sphincterotomy and followed by further endoscopic procedures to extract stone fragments. 

Now, because of its external and non-invasive nature, your gastroenterologist can perform ESWL separately without performing an ERCP. When ESWL is performed as a separate procedure, you may use 47999 (Unlisted procedure, biliary tract) to report the administration of the lithotripsy. 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.

Myth 4: Only Modifiers 51 and 59 are Useful 

Multiple endoscopies rules apply when reporting bundled codes because they have the same base endoscopic code (43260). In allowed 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: Your GI places stent in both the pancreatic duct and the common bile duct during the same operative session, you may report 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) for each additional stent placed, using modifier 59 with the subsequent procedures(s).

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. For example, if the GI conducts a sphincteroplasty or dilation of a ductal stricture before proceeding to remove stones/debris from the duct during the same session, you should code 43264 and 43277. Most carriers will pay for the higher valued procedure at 100% and then pay the difference between the base code 43260 and the second procedure.

However, there’s a third modifier you can use successfully. If the gastroenterologist spends more time than usual on the stone extraction and the rest of the ERCP procedure, you can opt for attaching modifier 22 (Increased procedural services) to the procedure codes and requesting additional payment from the carrier. Keep in mind: Medicare requires extra documentation to be sent with the original claim when you use modifier 22. Carriers will expect the documentation to demonstrate a significant increase in work effort before considering extra payment.