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Gastroenterology Coding Alert

Gain $400 or More For 2 Easily Missed ERCP Components

Published on Thu Nov 27, 2008

Your MD needs to document these items to report fluoroscopy codes

Coding an endoscopic retrograde cholangiopancreatography (ERCP) does not always mean a one CPT code situation. If your gastroenterologist performs a sphincterotomy, multiple ERCPs or stents, or a fluoroscopy, you may report additional codes and add $400 -- or more -- to your practice's bottom line.

Recoup $400 for Sphincterotomy

Suppose your gastroenterologist performs a pancreatic stent placement during an ERCP for sphincterotomy.

In this case, you can report 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). "You do not need to attach any modifiers," says Jennifer Lawrence, CPC, patient accounts manager at Westside Gastroenterologists, Inc. in Middleburg Heights, Ohio.

CPT specifically allows you to report both procedures. The parenthetical instruction following 43268 states, "When [43268 is] done with sphincterotomy, also use 43262."

Highlight: If you failed to include 43262, you would miss out on $400, based on national averages.

Bonus: Some third-party payers may allow you to report stent replacements (for instance, if an existing stent becomes occluded, and therefore the gastroenterologist must remove it and insert a new stent) using both the stent removal code 43269 (...with endoscopic retrograde removal of foreign body and/or change of tube or stent) and the stent placement code 43268. Medicare and many other payers, however, always bundle the placement (43268) into the removal (43269) and will not pay separately for the placement.

Get Double the Reimbursement for Second Stents

If your physician performs an ERCP and places a stent into the common bile duct and a second stent into the pancreatic duct, you can report 43268 twice. That's an additional $370, based on national averages.

Heads up: If your gastroenterologist places multiple stents ERCP, then you can report your ERCP code multiple times -- but in these cases, you need to include modifier 59 (Distinct procedural service). For instance, if your gastroenterologist places multiple pancreatic stents during an ERCP, you would report 43262, 43268, and 43268-59.

Sphincterotomy exception: The same is true for multiple sphincterotomies -- but this is only true for cases with unusual anatomy (such as pancreatic divisum). If your gastroenterologist performs both a biliary and pancreatic sphincterotomy at different sphincters (the major and minor papilla), you would report 43262 and 43262-59.

Note: For more information about using modifier 59, turn to "Capture Modifier 59 Opportunities With 2 Do's" on page 91.

Usually Include These Fluoro Codes

Fluoroscopy 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 standard components of a diagnostic ERCP. In most cases, you do not report them separately from the ERCP.

Bundled: The AMA has long advised that you should not report 76000 or 76001 separately with ERCP procedures 43260-43272 (CPT Assistant, Spring 1994). In the third quarter of 2003, the Correct Coding Initiative (CCI) further solidified this guideline by bundling 76000-76001 to 43260-43272 for all Medicare payers and others who follow CCI restrictions.

Fixate on These $35-$45 S&I Possibilities

In limited circumstances, however, you may be able to report ERCP radiologic supervision and interpretation using 74328 (Endoscopic catheterization of biliary ductal system, radiological supervision and interpretation) which reimburses about $35, 74329 (Endoscopic catheterization of the pancreatic ductal system ...) which equals around $35, or 74330 (Combined endoscopic catheterization of the biliary and pancreatic ductal systems ...) which pays about $45, as appropriate.

Caution: Before reporting S&I, make sure you check off three items:

• The gastroenterologist must indicate in his notes that he supervised the ERCP, and he must also include in the note his interpretation of the procedure. "As with any imaging code, the physician does not have to personally operate the fluoro machine, but he is required to supervise the technologist who is operating it and must interpret the images. The op report should indicate that fluoro was used and what the findings were," says Jackie Miller, RHIA, CPC, a coding expert and senior coding consultant for Coding Strategies, Inc., in Powder Springs, Ga.

• No other physician may claim the same service. Problem: In a facility setting, the facility radiologist may have priority for all interpretations. If the hospital radiologist reports 74328-74330, the gastroenterologist may not report the service, even if he prepares a separate report. Insurers will pay for the interpretation and report only one time.

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

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