Optimize Reimbursement for ERCPs
Published on Thu Jun 01, 2000
When coding for an endoscopic retrograde cholangiopancreatography (ERCP), gastroenterologists often are confused by what services can be reported separately with the procedure. In addition, Medicare, CPT and private insurance companies are different in how they expect coding and reimbursement issues surrounding this family of codes (43260-43272) to be handled.
An ERCP is done to evaluate and visualize the hepatobiliary system, which includes the pancreatic ducts, hepatic ducts, common bile ducts, duodenal papilla (also known as the ampulla of Vater) and the gallbladder, according the Kathy Anderson, RN, director of nursing and plant manager at the Indianapolis Endoscopy Center. A side-viewing endoscope is passed orally into the duodenum, where a cannula or hollow tube is inserted into the duodenal papilla and injected with contrast material that allows the gastroenterologist to visualize the entire hepatobiliary system with the aid of a fluoroscopy.
Fluoroscopy and EGD Not Separately Billable
The use of contrast material and the fluoroscopy is a standard component of ERCPs, say Anderson, which is why the fluoroscopy is bundled into the ERCP code (43260-43272) and cannot be billed separately with code 76000. The Spring 1994 CPT Assistant also emphasizes that point when it states that ERCP is always performed with fluoroscopy, and no separate fluoroscopy code should be reported by the endoscopist in these cases.
Esophagoscopy (43200) and upper gastrointestinal endoscopy (43235) also are bundled by Medicare into the ERCP code and cannot be reported separately. While you are using a front-viewing scope with an esophagogastroduodenoscopy (EGD) and cant do the same diagnosis with the side-viewing scope used for an ERCP, you are passing the scope along the same path in the body, says Anderson.
If an EGD with biopsy (43239) is performed in the same session as an ERCP with removal of stones (43264) and both services are reported, Medicare will deny the higher-valued service and pay the lower-valued one. In this case, there would be a significant loss of revenue because the ERCP with removal of stones, which has a relative value unit (RVU) of 14.67, would be denied, and the EGD with biopsy, which has an RVU of 4.93, would be reimbursed.
Code for an ERCP Instead of an EGD
One way to handle this situation is to code the EGD with biopsy as an ERCP with biopsy (43261), according to Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn. The standard practice in coding is to code for the endoscopic family in which the gastroenterologist was able to advance the scope, she explains. If the scope was extended into the hepatobiliary system for reasons of medical necessity, then it is appropriate to report the work done as an ERCP.
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