Gastroenterology Coding Alert

Question: Our gastroenterologist performed an ERCP without a pancreatogram. He briefly tried to inject but was unsuccessful. He did an ERCP without a cholangiogram in another patient. Again, multiple attempts failed. Are these considered regular ERCPs (43260) or do we have to attach a modifier?

Illinois Subscriber

Answer: The formal name for an ERCP is an endoscopic retrograde cholangio-pancreatography, from which you can see that a cholangiogram (visualization of the bile ducts) and pancreatogram (visualization of the pancreatic ducts) are integral parts of the standard procedure. However, it is probably appropriate to bill for a complete ERCP if you were able to visualize only one duct.

If there are problems visualizing both sets of ducts, then its an incomplete procedure, according to Pat Stout, CMC, CPT, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

There are two modifiers that you could attach to the ERCP code to indicate an incomplete procedure: modifier -52 (reduced services) or modifier -53 (discontinued procedure).

Modifier -52 will probably be required by commercial payers who strictly follow CPT coding principles, says Stout. CPT states that it should be used when under certain circumstances a service or procedure is partially reduced or eliminated at the physicians discretion. This is, says Stout, the most appropriate modifier to use.

Because the CPT definition for modifier -53 states that it is to be used when due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued, Stout doesnt feel that this is the appropriate modifier for this procedure, but it might be accepted by some Medicare carriers.

The catch with this coding situation is that some Medicare carriers may require modifier -53 like they do for an incomplete colonoscopy (45378-53), she explains. The only way to know for sure is to check with your carrier.

Because the visualization of the ducts is an important part of the ERCP procedure, however, Stout says you should be prepared to receive no reimbursement or a significantly reduced payment for a procedure in which this was attempted but not achieved.