Gastroenterology Coding Alert

Question: In the article Optimize Reimbursement for ERCPs on page 43 of the June 2000 Gastroenterology Coding Alert, gastroenterologists are advised to report only 43269 when removing an old biliary stent and replacing a new one. A gastroenterology coding consultant says that we should use 43268 and 43269-59 to report the removal and replacement.

If we can only report one code, why cant we report code 43268, which has a higher relative value unit (RVU)?

Kentucky Subscriber

Answer: In the article that you cited, it was mentioned that there is a difference of opinion between Medicare and CPT on how to report for both the removal and subsequent replacement of a biliary stent.

Code 43268 (endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) which has a transitioned facility RVU of 13.53, is used to report the endoscopic insertion of a tube or stent into the bile or pancreatic duct. Code 43269 (ERCP with endoscopic retrograde removal of foreign body and/or change of tube or stent) which has a transitioned facility RVU of 11.06, is used to report the endoscopic removal and/or change of a tube or stent.

Your coding consultant is probably referencing an article in the spring 1994 CPT Assistant that states, if a stent is already in place, but must be replaced (perhaps because it has become occluded), 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.

Private payers that follow CPT guidelines might accept both codes, says Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn. She encourages gastroenterologists to check with those payers to see what their coding and payment policies are regarding biliary stent removal and replacement.

When it comes to Medicare, however, only 43269 should be reported for a stent replacement and removal, according the Barbara Kallas, billing specialist for Gastroenterology Consultants, a practice with 10 gastroenterologists in Milwaukee. Code 43268 is bundled into code 43269 (in Medicares Correct Coding Initiative), so you can only report the removal and change code (43269), Kallas explains.

While you may choose to report 43268 because it is a higher-paying code and may be reimbursed for it, the phrase change of tube or stent in the definition of code 43269 leads most coding professionals to believe that this code more accurately reflects the procedure that took place.

You may also run into trouble during an audit. If a gastroenterologist documents the initial insertion of a stent and a few weeks later records a removal and replacement of the stent as an insertion only, then it will look like the gastroenterologist inserted two stents in the patient. This is physically impossible and medically unnecessary, Stout says. For this situation to make sense from a medical point of view, the removal of the stent has to be documented on the patients medical record.

Additional assistance for Reader Questions and You Be The Coder was given by Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn.; and Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a member of the American Medical Associations CPT advisory panel.