Gastroenterology Coding Alert

Question: How should I report an ERCP (endoscopic retrograde cholangiopancreatography) with stent placement and injection therapy for bleed control? The operative report reads that there was mild oozing at the papillotomy, and this was injected with 2.5 cc of epinephrine to control the oozing. The pancreatic duct was not injected. This is a post-liver transplant patient with anastomotic bile structure. What codes should I use?

Minnesota Subscriber

Answer: You should report the ERCP with stent placement with 43274 (Endoscopic retrograde cholangiopancreatography [ERCP]; with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent).

Whether you can separately report the injection therapy for the control of bleeding depends on what caused the bleeding. The bleeding is most likely a result of the papillotomy (a surgical incision made at the papilla of Vater, also referred to as a sphincterotomy) performed by your gastroenterologist.

In that case, you cannot bill separately for the injection therapy because Medicare and most private insurers have a you-break-it-you-fix-it policy. When a complication described by codes defining complications arises during an operative session, however, it is incorrect to report a separate service for treating such complications, states the National Correct Coding Policy Manual for Medicare Part B Carriers (also known as the National Correct Coding Initiative [CCI]).

If the incision did not cause the bleeding, you can bill the injection therapy with EGD with control-of-bleeding code 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method) because you won’t find a code for ERCP with control of bleeding. The endoscope used for the injection therapy will follow basically the same route that it would with an EGD.

CCI does not bundle 43255 with 43268, but you may want to attach either modifier 51 (Multiple procedures) or 59 (Distinct procedural service) (depending on your payer requirements) to the control-of-bleeding code to indicate that it is a separate and distinct procedure.

If the gastroenterologist performed the papillotomy (sphincterotomy) during this same session, you can bill that service separately with 43262 (Endoscopic retrograde cholangiopancreatography; with sphincterotomy/papillotomy).