Gastroenterology Coding Alert

Question: Our physician performed multiple procedures on his patient, ‘43262’ ERCP with sphincterotomy, ‘43277’ ERCP with balloon dilation, ‘43261’ ERCP with biopsy and he is now asking me to add brushing to this case. Can this be billed with another code?

Michigan Subscriber

Answer:  When billing multiple ERCP procedures, you’ll need to remember that some of the new codes for ERCP introduced in 2014 carries the guidelines that sphincterotomy should not be reported separately.

If you look at the descriptor to 43277 (Endoscopic retrograde cholangiopancreatography [ERCP]; with trans-endoscopic balloon dilation of biliary/pancreatic duct[s] or of ampulla [sphincteroplasty], including sphincterotomy, when performed, each duct), you’ll see that it includes “sphincterotomy.” 

Also, Correct Coding Initiative (CCI) edits bundle 43262 (…with sphincterotomy/papillotomy) with 43277 with the modifier indicator ‘1.’ This code bundling can however be broken down if you use a modifier such as -59 (Distinct procedural service) with 43262. But, you will only use the modifier if the dilation and the sphincterotomy were performed by your clinician in two different sites and not at the same location.  This would generally mean treatment at both the major papilla and minor papilla as can happen with a rare case of pancreatic divisum.

Again, if you look at the descriptor to 43260 (…diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) which covers the brushing, you will see you are allowed to report this code only if the brushing is a standalone procedure and your clinician does not perform any other procedure. Since, you are claiming for other ERCP procedures for the same session, it will be incorrect if you follow your physician’s instructions and report 43260 in addition to the other procedures.

So, in this case, you will only have to report 43261 (…with biopsy, single or multiple) for the biopsy and 43277 for the dilation.