Gastroenterology Coding Alert

Question: My doctor has recently begun placing pancreatic stents during ERCP to decrease the risk of post-ERCP pancreatitis and to allow access to the bile duct. He is also placing biliary stents to prevent the bile duct from swelling shut. What diagnosis code should I use for these stent placements? Also, would I bill 43268 once or twice?

Michigan Subscriber

Answer: Your question suggests that this is a preventive procedure, which makes it difficult to choose an appropriate diagnosis and may make it difficult for you to get paid for that portion of the procedure.

Two common diagnosis codes used with 43268 (ERCP; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) are obstruction of bile duct (576.2) or bile duct stones (574.50). If your operative note states that this was a preventive measure, however, these are not appropriate diagnosis codes. You will also probably not get reimbursed because Medicare and most commercial insurers generally do not pay for preventive services. The insurer's reasoning would probably be that the stent placement was not medically necessary because you don't know if the patient would have developed pancreatitis. 

Your gastroenterologist should be more precise in the operative note about why he or she did the stent placement. If bile-duct stones were found and the stents were placed to keep any remaining stones from getting lodged in the duct, you should use 574.50. If the patient was already suffering from pancreatitis, you could use that diagnosis code, 577.0 (acute pancreatitis). Tell your gastroenterologist to explain to you why he or she believed that ducts would swell shut and then try to use that definition as your diagnosis. 

As for your second question, you will probably be able to bill 43268 only once -- even if stents were placed in both the bile and pancreatic ducts. While this might vary from payer to payer, most seem to pay only once for the procedure.

 
If you placed the stents in combination with a removal of stones, you should report two codes, 43268 and either 43264 (... with endoscopic retrograde removal of stones[s] from biliary and/or pancreatic ducts) or 43265 (... with endoscopic retrograde destruction, lithotripsy of stone[s], any method), depending on whether the stones were removed or destroyed.

 

 -- This month's "Reader Questions" and "You Be the Coder" were answered by Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 23-physician practice.