Gastroenterology Coding Alert

Question: Two weeks ago, the gastroenterologist performed an endoscopic retrograde cholangiopancreatography (ERCP) on a patient that may or may not have been a complete ERCP. The gastroenterologist tried multiple times to visualize the bile ducts, but was only able to visualize one of them. Will insurance companies consider this a full ERCP, or should we append a modifier to the code?

Kentucky Subscriber

Answer: Report 43260 (Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) even though the doctor didn't achieve full bile-duct visualization. Although visualization of the bile ducts, or cholangiography, is technically part of an ERCP, you should still report a complete ERCP as long as the doctor visualized at least one bile duct.

If there are problems visualizing both ducts, however, it is an incomplete procedure and the code should be appended with a modifier before being presented to the insurance carrier.

Use modifier -52 (Reduced services) when reporting an incomplete ERCP to private payers. Modifier -52's CPT definition reads, "Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion," making it the appropriate modifier in this situation.

When reporting incomplete ERCPs to Medicare, some coders have  success using modifier -53 (Discontinued procedure) rather than modifier -52, but that decision is up to each local medical review policy (LMRP). Check your local LMRP for coding guidelines on discontinued ERCPs.

Warning: Duct visualization is a vital part of any ERCP, and failure to perform it may result in either no reimbursement or a significantly reduced payment.

-- Clinical and coding expertise for You Be the Coder and Reader Questions was provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel; and Linda Parks, MA, CPC, CCP, coding and billing coordinator for GI Diagnostic Endoscopy Center in Marietta, Ga.