Gastroenterology Coding Alert

"Gastroenterologists often fail to report all the services performed while extracting stones during an endoscopic retrograde cholangiopancreatography (ERCP). They mistakenly believe that these services are bundled by the national Correct Coding Initiative or are considered integral parts of the extraction and cannot be separately reported. Its not difficult to understand the confusion because there are some services, such as fluoroscopy or cholangiograms, that are considered standard components of ERCP and cannot be billed separately.

Report 43264 for Stone Removal

An ERCP is performed to extract stones that have lodged in the bile or pancreatic ducts. Code 43264 ERCP; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure] with endoscopic retrograde removal of stone[s] from biliary and/or pancreatic ducts) is used to report the removal of stones. Two commonly used devices for stone removal are a basket and a balloon, according to Anil Minocha, MD, FACP, FACG, chief of gastroenterology at the Southern Illinois School of Medicine and the author of 2000 Minochas Guide to Digestive Disease.

A catheter with a basket is passed over a guide wire into the duct and the basket traps the stone, which is then withdrawn into the duodenum and let loose, explains Minocha. A balloon also can be used to drag out the stones.

You should report the code once, says Sandi Scott, CPC, CORT, president of the AAPC South Beach chapter, and director of coding at the Mission Internal Medicine Group in Mission Viejo, Calif. The CPT definition of 43264 says, stone(s), so it doesnt matter about the number of stones removed or the number of methods used.

Balloon Dilation of Ducts Billed as a Separate Procedure

The use of a balloon to remove stones should not be confused with the balloon dilation of the ampulla, biliary or pancreatic ducts, which is a separate procedure reported with code 43271 (ERCP with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic ducts). Ductal dilation is done when there is a stricture of one of the ducts, says Minocha. Even the balloons used for the two procedures are different. For the stones themselves, no ductal dilation is done.

Lithotripsy with ERCP Is Reported with 43265

The gastroenterologist also may use lithotripsy to crush and destroy the stones. Code 43265(ERCP with endoscopic retrograde destruction, lithotripsy of stone[s], any method) is used to report the destruction of stones when performed in conjunction with an ERCP. Mechanical lithotripsy is a commonly used method for stone destruction, in which a catheter is inserted directly into the duct and crushes the stones. Another method is 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. As with the stone removal, 43265 is only reported once, regardless of the number of stones destroyed or methods used.

Because it is administered outside of the body, ESWL can also be performed separately without performing an ERCP, according to Barbara Kallas, billing specialist for Gastroenterology Consultants, a practice with 10 gastroenterologists in Milwaukee. When ESWL is performed as a separate procedure, Kallas recommends using 47999 (unlisted procedure, biliary tract) to report the administration of the lithotripsy. Because this is an unlisted procedure code, a copy of the operative report and a description of the procedure should also be included with the claim.

Coding the Removal and Destruction of Stones

Many gastroenterologists use both removal and destruction methods during the same session to extract stones and coders often make the mistake of thinking these are mutually exclusive codes that cannot be reported together. But, the CPT manual recognizes them to be significantly different procedures that can be reported separately.

Medicares multiple endoscopies rules apply when reporting both extraction codes because they have the same base endoscopic code (43260). Code 43264, with a transitioned facility relative value unit (RVU) of 15.82, should be reported first because it is the higher-valued procedure. Reimbursement will be 100 percent of the allowed fee.

Code 43265, with a transitioned facility RVU of 14.67, should be reported with modifier -51 (multiple procedures) attached because it is the lesser-valued procedure, according to Kallas. The Medicare Carriers Manual states that modifier -51 should be used if the procedures are not bundled. Some payers may require the use of modifier -59(distinct procedural service). Reimbursement will be the difference between the allowed fee for 43265 and its base endoscopic code, 43260.

Use Modifier -22 for Extra Time

If the gastroenterologist spends more time than usual on the stone extraction and the rest of the ERCP procedure, coders may want to consider attaching modifier -22 (unusual procedural services) to the procedure codes and requesting additional payment from the carrier, suggests Michael Weinstein, MD, a gastroenterologist in Washington, D.C. and a member of the American Medical Associations CPT advisory panel.

Medicare requires extra documentation be sent with the original claim when modifier -22 is used. Carriers will expect the documentation to demonstrate a significant increase in work effort before considering extra payment.

Sometimes the gastroenterologist cannot successfully extract the stone, often because it is too large. The removal and/or destruction codes can still be reported, however, even when the procedure is not completely successful. The process is very time-consuming and requires as much work, even though a stone is not removed, explains Scott.

How to Report a Sphincterotomy

Sphincterotomy (43262), a procedure where the opening of the sphincter of Oddi is enlarged so that it is easier to remove stones or insert a tube, is another procedure that gastroenterologists may mistakenly believe is bundled with other services because it is frequently performed in conjunction with a stone extraction. The code, however, is not bundled by Medicare into the removal or destruction codes and can be reported separately, according to Kallas. There is also a note included in the CPT definitions for codes 43264 and 43265 that states [w]hen done with a sphincterotomy, also use 43262.

Visualization Not Billed Separately

Finally, there are several procedures that are considered an integral part of the ERCP and cannot be reported separately when done as part of the stone extraction. The collection of specimen(s) by brushing or washing, for example, is considered a standard component of the procedure. In this case, CPT indicates that this is a standard component by following it with the phrase separate procedure in the definition of the endoscopic base procedure code 43260.

Visualization is also a standard component of all ERCPs. A fluoroscopy is frequently used to visualize the entire hepatobiliary system, but the spring 1994 CPT Assistant states that ERCP is always performed with fluoroscopy, and no separate fluoroscopy code should be reported by the endoscopist in this case.

A cholangiogram is another form of visualization where contrast material is injected into the bile ducts to see if there are any stones present after an extraction has taken place. This also is considered a standard part of the ERCP and is not separately billable, according to both Scott and Kallas.
 

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