Gastroenterology Coding Alert

You can report both procedures together --  here's how

Stymied by stone extraction codes 43264 and 43265? We-ve got everything you need to know about endoscopic retrograde cholangiopancreatographies (ERCPs) and tips on how to ethically maximize your reimbursement.

Keep in mind: -Sometimes physicians are unable to remove the stone completely, but they are still able to remove debris and sludge. You should still code this as a stone extraction,- says Lois E. Curtis, MHA, CPC, insurance and billing manager for Gastroenterology Associates in Evansville, Ind.

Read Up on Stone Removal

Your gastroenterologist performs an ERCP to extract stones that have lodged in the bile or pancreatic ducts. You should use 43264 (ERCP; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts) to report the stone removal. Two commonly used devices for stone removal are a basket and a balloon.

What happens: The gastroenterologist passes a catheter with a basket over a guidewire into the duct. The basket traps the stone, which is then withdrawn into the duodenum and let loose. He may also use a balloon to drag out the stones.

Rule of thumb: -You should report the code once,- Curtis says. -The CPT definition of 43264 says -calculus/calculi,- so it doesn't matter about the number of stones removed or the number of methods used.-

Watch out: You shouldn't confuse the use of a balloon to remove stones with the balloon dilation of the ampulla, biliary or pancreatic ducts, which is a separate procedure you should report with 43271 (ERCP; with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct[s]). Your gastroenterologist will perform a ductal dilation when the patient has stricture of one of the ducts. Even the balloons used for the two procedures are different. For the stones themselves, the gastroenterologist will not perform any ductal dilation.

Determine Code for Stone Destruction

Your gastroenterologist may also use lithotripsy to crush and destroy the stones. You should report 43265 (ERCP; with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method) for the stone destruction when the GI performs this procedure with an ERCP. GI physicians commonly use mechanical lithotripsy for stone destruction, in which the GI inserts a catheter directly into the duct and crushes the stones.

How to Code Both Removal, Destruction

Avoid this mistake: Many gastroenterologists use both removal and destruction methods during the same session to extract stones, and coders often assume these procedures are represented by mutually exclusive codes they cannot report together. But your CPT manual recognizes them to be significantly different procedures you can report separately, Curtis says.

Medicare's multiple-endoscopy rule applies when reporting both extraction codes because they have the same base endoscopic code (43260, Endoscopic retrograde cholangiopancreatography [ERCP]; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

You should report 43265, with a work relative value of 10.00, first because it is the higher-valued procedure. Reimbursement will be 100 percent of the allowed fee.

You should report 43264, with a work relative value of 8.89, with modifier 51 (Multiple procedures) attached because it is the lesser-valued procedure. -I recommend adding modifier 51 on the second procedure,- says Sherry Searson, CPC, MCS-P, billing and coding supervisor at Charleston Gastroenterology Specialists in South Carolina. Some payers, however, may require you to use modifier 59 (Distinct procedural service) instead. But in either case, reimbursement will be the difference between the allowed fee for 43265 and its base endoscopic code, 43260.

Use Modifier 22 for Extra Time

Your modifier options don't end with modifiers 51 and 59.

If your gastroenterologist spends more time than usual on the stone extraction and the rest of the ERCP procedure, you may want to consider attaching modifier 22 (Unusual procedural services) to the procedure codes and requesting additional payment from the carrier, Searson says.

Make sure you send in extra documentation with the original claim when you use modifier 22. Carriers will expect the documentation to demonstrate a significant increase in work effort before considering extra payment. -Send in your claim with the op note attached and a note from the physician explaining and describing the difficulty of this particular case,- Searson says.

Bottom line: -The more information included in the documentation, the greater your chances of getting additional reimbursement,- Curtis says.

Bonus: Seek 43262 for Sphincterotomy

In most cases, your gastroenterologist will need to cut the major papilla to get the stones out. If your gastroenterologist performs a sphincterotomy, you can report this procedure separately from a stone extraction. You should use 43262 (Endoscopic retrograde cholangiopancreatography; with sphincterotomy/papillotomy).