Gastroenterology Coding Alert

Question: The gastroenterologist performs a level-two office visit on a new patient, and then decides to perform an endoscopic retrograde cholangiopancreatography (ERCP) using fluoroscopic guidance. During the encounter, the gastroenterologist also performs a sphincterotomy. How many CPT codes can I report for this encounter?

Tennessee Subscriber

Answer: Most likely, three. On the claim, you'll probably report the following:

• 43268 (Endoscopic retrograde cholangiopancreatography; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) for the ERCP

• 43262 (Endoscopic retrograde cholangiopancreatography; with sphincterotomy/papillotomy) for the sphincterotomy

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...)

for the E/M service assuming the physician based his decision to do the procedure on this initial evaluation

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 99202 to show that it was separate from the ERCP and sphincterotomy.

Watch out: You can report this modifier if your physician documents the need for surgery. In other words, if this was a pre-planned surgery and the E/M was only for the history and physical (H&P), then you should not report the E/M service separately.

Guidance on guidance: The provider will use fluoroscopy in most ERCP scenarios; therefore, 76000 (Fluoroscopy [separate procedure], up to 1 hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) and 76001 (Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]) are bundled into 43268.