Gastroenterology Coding Alert

Question: During a single visit with a patient, my physician performed an endoscopic retrograde cholangiopancreatography (ERCP) with removal of stones and an upper gastrointestinal endoscopy (EGD) with biopsy. Can I bill these separately?  

Oregon Subscriber Answer: Yes, you can, if two endoscopes were used. Code the ERCP with removal of stones 43264 (Endo-scopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts). The proper code for the EGD with biopsy is 43239 (Upper gastrointestinal endoscopy ...; with biopsy, single or multiple) with modifier -59 (Distinct procedural service).
 
In the old days, the National Correct Coding Initiative (NCCI) edits bundled any ERCP and EGD performed during the same session. Medicare removed many of these ERCP/EGD edits a few years back, yet some gastroenterology practices are losing money by billing as if the bundles still exist. It's a different ballgame today; even some ERCP/EGD combinations that are still bundled together in the NCCI may be overridden with the proper modifier - if it can be proven that the two procedures are separate and distinct.
 
But remember, you can only report both codes when two scopes are necessary to perform the entire procedure and documentation supports the need for the second endoscope. A physician could take a biopsy with the ERCP scope from a location in the upper gastroenterological system without the need for a second endoscope. In that case you should report 43261 (Endoscopic retrograde cholangiopancreatography ...; with biopsy, single or multiple) alone, or 43261 with modifier -59 and any other therapeutic ERCP code that is necessary.
 
To code ERCPs and EGDs properly, coders must understand the differences between these procedures, which both involve passing a scope through the esophagus to the duodenum. An EGD is done to evaluate symptoms of persistent upper-abdominal pain, nausea, vomiting, or difficulty swallowing. An ERCP, on the other hand, evaluates and visualizes the hepatobiliary system, which includes the pancreatic ducts, hepatic ducts, common bile ducts, duodenal papilla (also known as the ampulla of Vater) and the gallbladder.