Gastroenterology Coding Alert

Question: Our gastroenterologist performed an ERCP to facilitate obtaining a retrograde cholangiogram. He then removed the stent. Should I bill for the stent placement or removal, or simply charge for the ERCP?

South Dakota Subscriber

Answer: Your scenario sounds as if the stent was already in place when the procedure began, so you would be safe to use 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent). Considering the code's definition, many gastroenterologists think this most aptly describes the procedure.

On the other hand, if the gastroenterologist placed the stent during the procedure, you should report 43268 (... with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) even if he removed the stent at the end of the procedure.

Keep in mind: The Correct Coding Initiative (CCI) lists the stent placement and removal codes as mutually exclusive, which means they cannot be "reasonably done in the same session." Because of this edit, most gastroenterology practices do not report the stent placement separately when the gastroenterologist does this procedure with stent removal.

On the other hand, some practices have billed only 43268 because CCI's introduction says that if you report both codes that make up a mutually exclusive edit, Medicare will pay the lower-valued code. Other practices have reported 43269 because it's the higher-valued procedure.

More recently, some practices began billing both the stent placement and removal because the edit contains a modifier indicator of "1," which means you can override this edit with a modifier and differentiate between the services provided. Important: This only allows for gastroenterologists to receive reimbursement for stents placed and removed in different ducts and is not intended for when the physician removes and replaces a stent in the same duct.

You cannot code for the cholangiogram, which is a form of visualization during which the physician injects contrast material into the bile ducts to see if any stones are present after an extraction. This, along with other visualization techniques, is an integral part of an ERCP and is not separately billable.