Gastroenterology Coding Alert

Here's what to look for in your documentation when choosing S&I code

Saying "endoscopic retrograde cholangiopancreatography (ERCP)" is hard enough, but coding these services can be even trickier. Two real-world scenarios show you how to sort through 43260-43272 and use the codes correctly every time.

Start With Stent Removal From Bile Duct

Your physician uses an endoscope to remove a stent from the bile duct. How should you code this?

To report this service, you'll rely on 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent). If your gastroenterologist also reports his own x-ray guidance, you'll likely also use 74328-26 (Endoscopic catheterization of the biliary duct system, radiological supervision and interpretation; professional component).

Red flag: Your physician won't perform this procedure in the office, so you have to add modifier 26 to the radiology code to show that he's using the facility's equipment and having the technician available at the facility, says Deb Rooth, CPC, LVN, lead coder for Mission Internal Medical Group in Mission Viejo, Calif.

In limited situations, you may be able to report ERCP radiologic supervision and interpretation using 74329 (Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation) or 74330 (Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation), as well as 74328, depending on your gastroenterologist's documentation.

"You'll have to read the dictation to determine which code applies anatomically, as you've got biliary (74328) versus pancreatic (74329) systems, or both (74330)," Rooth says.

Get this: "A typical note will go on about an 'occlusion cholangiogram performed revealed good filling of the right (or left, or both sides) hepatic system. No filling defects seen,'" Rooth says. "Or the physician will describe them: 'The ball tip catheter was inserted into the common bile duct. At this time, 40cc of contrast material was aspirated. The specimen was submitted for cytology. No residual contrast material was seen within the biliary system after this maneuver.'"

Important: To report these radiological services, you'll need to follow these guidelines:

The gastroenterologist must indicate in his notes that he supervised the fluoroscopy and taking of radiographs for the ERCP, and he must also include his interpretation of the procedure in this documentation.

No other physician coder may claim the same service. This can be problematic because, in a facility or hospital setting, the facility radiologist may have priority for all interpretations. If the hospital radiologist reports 74328-74330, your gastroenterologist can't submit a claim for any radiology CPT code, even if he prepares a separate report, because carriers will pay for only one interpretation.

Make sure to append modifier 26 to 74328-74330, as appropriate, if your physician provides the radiological reading service in the facility setting.

Try Your Hand at Basket Technique Scenario

During an ERCP, your gastroenterologist extracts four stones from the patient's pancreatic duct using the basket technique.

What it is: The basket technique describes when your physician places a catheter with a basket over a guidewire into the biliary ducts. She then uses the basket to scoop up the stone(s), which she then withdraws into the duodenum where she releases them.

To report this procedure, you should use 43264 (... with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts). "Even if the gastroenterologist doesn't find any debris, you should still report 43264," says Susan Williams, CPC, CGCS, coder at Austin Gastroenterology PA in Texas.

Important: You should submit a single unit of 43264, regardless of the number of calculi the physician extracts. And you would stick with this code if the gastroenterologist uses a balloon to remove the stones rather than a basket.

Warning: You might be tempted to report 43271 (... with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct[s]) in addition to 43264, but you shouldn't because there's no ductal dilation when the physician removes calculi, even if she uses a balloon during the procedure.