Gastroenterology Coding Alert

Question: When reporting 43260 and 43239 at the same time, should I attach modifier -51 or -59?

Texas Subscriber

Answer: The Correct Coding Initiative bundles these two codes, which means they are not separately payable. If you report them together on the same claim, Medicare may deny the higher-valued service and pay the lower- valued one. In this situation, there would be a significant loss of revenue because the EGD code 43239 (upper gastrointestinal endoscopy (EGD) with biopsy), which would be reimbursed, has a transitioned facility relative value unit (RVU) of 4.93, and the ERCP code 43260 (endoscopic retrograde cholangiopancreatography [ERCP]), which would be denied, has a transitioned facility RVU of 10.59.

If a biopsy is performed during the course of an ERCP, the correct code is 43261 (ERCP with biopsy) regardless of whether it is the ampulla, biliary duct or stomach being biopsied. The standard practice in coding is to code for the endoscopic family in which the gastroenterologist was able to advance the scope. If the scope was extended into the hepatobiliary system for reasons of medical necessity, it is appropriate to report the work done as an ERCP. Because you will be reporting only one code, no other modifier is needed.

Answers for this months Reader Questions were provided by Pat Stout, CMT, CPC, an independent coding consultant in Knoxville, Tenn.