Gastroenterology Coding Alert

Question: How should I code for an ERCP with an extension of sphincterotomy, removal of common bile-duct sludge, and the placement of a stent? Is sludge considered a foreign body? Is an extension of sphincterotomy the same as a sphincterotomy?

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Answer: The original placement of an ERCP stent is reported with 43268 (ERCP with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct). If this is a stent replacement, there are many different opinions on how to report the removal of the old stent and the insertion of a new one. Many gastroenterology practices still report 43268 in this situation, while others report 43269 ( removal of foreign body and/or change of tube or stent). Other practices report both codes. For more on stent replacements, see "Aggressive Coding Practices for ERCP Stent Placements Aim for Higher Payments," on page 65 of the September 2001 Gastroenterology Coding Alert.
 
As for the other procedures, sludge is another term for crushed stones and is removed in the same manner that stones are. This procedure should be reported with 43264 ( removal of stone[s] from biliary and/or pancreatic ducts). The extension of sphincterotomy is the same thing as a sphincterotomy; the gastroenterologist is reslicing the incision. The extension should be reported with 43262 (ERCP with spincterotomy/papillotomy).
 
Depending on your payer's requirements, modifier -51 (multiple procedures) or modifier -59 (distinct procedural service) should be attached to 43262 and 43264 to indicate that these were separate and distinct procedures.