Gastroenterology Coding Alert

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.

In this example, Stout recommends reporting code 43262 (endoscopic retrograde cholangiopancreatography [ERCP]; with sphincterotomy/papillotomy) first because it is the higher-valued procedure; reimbursement will be at the full value of the procedure. Code 43261 (endoscopic retrograde cholangiopancreatography [ERCP]; with biopsy, single or multiple) should be reported with modifier -51 (multiple procedures) attached. Payment will be the difference between the value of the ERCP with biopsy and the base endoscopic code 43260. Because not every commercial insurance company bundles the EGD code into the ERCP code, Stout recommends contacting the specific payer before using this approach to report these procedures.

Editors note: The Medicare Carriers Manual sections 4826(B) and 15900 state that the lesser-
valued surgical procedures should be reported with modifier -51. But this is not a requirement of every local Medicare payer or commercial insurance company. (For more on this, see Increase Reimbursement with Correct Modifiers and ICD-9 Codes on page 19 of the March 2000 Gastroenterology Coding Alert.)

Medicare, CPT Differ on Stent Removal

Another situation that frequently occurs with ERCPs is the placement and removal of biliary stents. The endoscopic insertion of a tube or stent into the biliary or pancreatic duct is reported with code 43268, which has an RVU of 13.53. The endoscopic removal and/or change of a tube or stent is reported with code 43269, which has an RVU of 11.06.

CPT has indicated that both codes should be reported if a stent is removed and then replaced. The Spring 1994 CPT Assistant states, If a stent is already in place, but must be replaced (perhaps because it has become occluded), code 43269 is used to describe the passage of an endoscope to remove the old stent and the above-described procedure (43268) for the placement of a new stent.

Medicare does not follow this practice, however, and has bundled 43268 into 43269. Gastroenterologists should report only 43269 when billing Medicare for the removal and replacement of a biliary stent. Stout believes that commercial insurance companies following CPT guidelines might accept both codes, and gastroenterologists should check with those payers to see what their coding and payment policies are regarding that procedure.

Report Sphincterotomy, All Methods of Removal

Many gastroenterologists use multiple methods to remove stones from the biliary and/or pancreatic ducts and make the mistake of thinking these are mutually exclusive codes that cannot be reported together. The endoscopic removal of stone(s) (43264) and endoscopic destruction of stone(s) (43265) are considered by CPT to be significantly different procedures that can be reported separately. Medicare does not bundle these codes together and also allows them to be reportedly separately when the medical necessity justifies both procedures.

Sphincterotomy (43262), 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. The code is not bundled by Medicare into other codes and can be reported separately if it is performed in conjunction with another service. Theres also a note included in many of the CPT ERCP code definitions that states [w]hen done with sphincterotomy, also use 43262.

When a sphincterotomy is performed and both methods of stone removal are used, Stout suggests that code 43264 should be listed first and that it will be reimbursed at its full value. Code 43265 should be listed with modifier -51 attached. Payment will be the difference between this procedure and the value of the endoscopic base code 43260. Code 43262 also should be listed with modifier -51 attached, and payment will be the difference between the value of the procedure and the value of the endoscopic base code 43260.

Unlisted Code Used for Some Procedures

Crystalline aspiration is another service performed during an ERCP, which often is used to determine whether there are previously undetected stones in the gallbladder, according to Barbara Kallas, billing specialist for Gastroenterology Consultants, a practice with 10 gastroenterologists in Milwaukee, Wis. An injection into the biliary ducts stimulates the production of bile so that a sample can be taken to do a crystalline analysis. CPT doesnt have a specific code for this service yet, states Kallas, who suggests that gastroenterologists bill it by reporting the diagnostic ERCP (43260) and 91299 (unlisted diagnostic gastroenterology procedure) for the aspiration. A description of the procedure and a copy of the operative report should accompany the claim, she adds.