Gastroenterology Coding Alert

Question: I’m coding an ERCP, and the gastroenterologist made numerous attempts with the catheter tip and with the guidewire — but these failed. Then he used the standard Hydratome, but over the course of an hour, the physician did not perform a single direct cannulation of either the common bile duct or pancreatic duct, nor did he insert the wire or contrast. Which modifier should I use for this?

North Dakota Subscriber

Answer: During an endoscopic retrograde cholangiopancreatography (ERCP), visualization of the bile ducts and the pancreatic ducts is an integral part of the standard procedure. If your gastroenterologist runs into problems visualizing any of the ducts (bile and pancreatic), he has performed an incomplete procedure.

You should report the session with 43260 (Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) and append the code with an appropriate modifier.

You have two modifiers that you could attach to the ERCP code to indicate an incomplete procedure: modifier 52 (Reduced services) or modifier 53 (Discontinued procedure).

Commercial payers that strictly follow CPT^® coding principles will most likely require modifier 52. CPT^® states that you should use this modifier when “under certain circumstances a service or the procedure is partially reduced or eliminated at the physician’s discretion.”

Because the CPT^® definition for modifier 53 states that you should use it when extenuating circumstances threaten the patient’s well-being, you may need to indicate that the physician started the ERCP but discontinued it. Some Medicare carriers may accept this method.

The catch: Some carriers may require modifier 53 as they do for an incomplete colonoscopy. The only way to know for sure is to check with your carrier.

Keep in mind: Because the visualization of the ducts is the purpose of the ERCP procedure, however, you should be prepared to receive no reimbursement or a significantly reduced payment for a procedure when your physician merely attempted but did not achieve the full procedure — no matter how long the attempted procedure lasted.

In fact, CPT^® instructs to report the EGD code (43235 if no biopsy) for failed ERCP; in unusual situations reporting this with 22 modifier (Increased procedural services) should at minimum allow for full payment of the 43235 service and sometimes extra consideration.  A comment in text field on the claim such as “spent 45 minutes, unsuccessful cannulation” or sending procedure note with scope-in to scope-out time and description of efforts/difficulty is usually needed to support use of 22 modifier.