Gastroenterology Coding Alert

Question: I have a gastroenterologist who did the following five procedures at once: ERCP with stent removal (43269), stone extraction (43264), sphincterotomy (43262), stent placement (43268) and a biopsy of the esophagus (43239). (The biopsy was done because an ulcer was found.) Is it ethical to bill all five procedures to a commercial insurer? What about Medicare? If it is not ethical, which ones should I report?

Vermont Subscriber

 
Answer: It is ethical to report legitimate multiple procedures. In fact, that is the only way to correctly report the services provided. You must be careful about billing combinations of procedures that are bundled in the Correct Coding Initiative (CCI) edits.
 
There is no question that you can bill 43264, 43262 and 43239 in combination. (You will also have to attach either modifier -51 [Multiple procedures] or -59 [Distinct procedural service] to the codes depending on your payers requirements to indicate that these are separate and distinct procedures.) The reporting of the stent removal (43269) and stent placement (43268) is complicated because these two codes are bundled.
 
The stent placement and stent removal codes are listed as a mutually exclusive edit in the CCI, 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 a stent removal because of this edit. Some practices billed only 43268 because the introduction to CCI states that the lower-valued procedure in a mutually exclusive edit should be billed. Others reported 43269 because it was the higher-valued procedure.
 
Recently, however, some gastroenterology practices have started billing the stent removal and stent placement because the edit is modified with a superscript of 1, which means that a modifier can be used to override the edit and differentiate between the services provided. This allows gastroenterologists to be paid for stents removed and placed in different ducts and is not intended in situations where a stent is removed and then replaced in the same duct.
 
(For more on ERCP stent placements, please see Aggressive Coding Practices for ERCP Stent Placements Aim for Higher Payments, on page 65 of the September 2001 Gastroenterology Coding Alert.)
 
You also have to be careful when billing an EGD with biopsy in combination with an ERCP because many of those procedures are bundled in the CCI edits. Code 43239 is not bundled with any of the codes in your example, however. (For more on this topic, please see Dont Code in the Past: Bill ERCP-EGD Combos Separately on page 60 of the August 2001 Gastroenterology Coding Alert.)
 
 
This months Reader Questions were answered by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.