Gastroenterology Coding Alert

Question: My gastroenterologist started performing an ERCP but couldn't find the ampulla of Vater. He was able, though, to biopsy a lesion in the patient's esophagus. Should I code this as a discontinued ERCP and try to code for the biopsy separately?

Alabama Subscriber

Answer: You're not the first to face finding a code for an incomplete endoscopic retrograde cholangiopancre-atography (ERCP) it comes with the territory so now it is only a matter of learning from others' mistakes.

Unlike with an esophagogastroduodenoscopy (EGD) or a colonoscopy, there aren't any guidelines for you to follow to determine whether your ERCPwas complete or incomplete. Coders approach this coding conundrum a number of ways:

If the ERCP can't be cannulated because the patient had a previous gastric bypass, some coders turn to modifier -53 (Discontinued procedure). If the ERCPtakes two attempts to be completed, some coders use 43260-22 (Endoscopic retrograde cholangiopancreatography [ERCP]; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]; Unusual procedural services). And in the scenario outlined in your question, it sounds as if you are going to have to report both an ERCPand an EGD with biopsy to correctly code your gastroenterologist's services.

You should code both the discontinued ERCP and the EGD with biopsy: 43260-53, 43239. The downside: Not only are the two procedures bundled by the NCCI edits, but you are already going to need additional documentation explaining why the ERCPprocedure was discontinued. If you decide to code the services using this method, append modifier -59 (Distinct procedural service) to 43239, coding this scenario 43260-53, 43239-59. This option assumes the gastroenterologist used two different endoscopes to perform the ERCPand to biopsy the lesion. If this is not the case, you would simple report a discontinued ERCPwith biopsy: 43261-53 ( with biopsy, single or multiple).

Some coders abandon the idea of using the ERCP code and instead report an EGD code with a biopsy: 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple). And others think it is a viable option to represent the procedure with the ERCPcode 43260 and append modifier -22 to indicate the additional time the gastroen-terologist had to spend to take the biopsy of the lesion. It is not recommended that you use either of these options down-coding an ERCPto an EGD is not proper coding if you want to submit a clean claim for the scenario you describe.