Gastroenterology Coding Alert

Question: Our gastroenterologist performed an ERCP to facilitate obtaining a retrograde cholangiogram. He then removed the stent. Should I bill for the stent placement or removal, or simply charge for the ERCP?

Oregon Subscriber

Answer: In your scenario, it sounds as if the stent was already in place when the procedure began, so you would be safe to use 43269. Considering the definition of the code, many gastroenterologists feel this most aptly describes the procedure. If the gastroenterologist placed the stent during the procedure, it would be correct to bill 43268 even if he removed the stent at the end of the procedure.

The National Correct Coding Initiative (NCCI) lists the stent placement and removal codes as mutually exclusive, which means they cannot be "reasonably done in the same session." Traditionally, gastroenterology practices have not billed separately for the stent placement when done in combination with stent removal because of this edit.

Some practices have billed only 43268 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) because the introduction to NCCI says to bill the lower-valued procedure in a mutually exclusive edit. Other practices have reported 43269 (... with endoscopic retrograde removal of foreign body and/or change of tube or stent) because it was the higher-valued procedure.

More recently, some practices began billing both the stent placement and removal because the edit contains an indicator of "1", which means a modifier can be used to override the edit and differentiate between the services provided. However, this only allows for gastroenterol-ogists to receive reimbursement for stents placed and removed in different ducts and is not intended in situations when the physician removes and replaces a stent in the same duct.

You cannot code for the cholangiogram, which is a form of visualization in which contrast material is injected into the bile ducts to see if there are any stones present after an extraction. This, along with other types of visualization techniques, is an integral part of an ERCP and is not separately billable.