Gastroenterology Coding Alert

Question: We performed stone removal during an endoscopic retrograde cholangiopancreatography (ERCP) and we aren’t sure how to code for removing three stones during the same session. Can you advise?

Codify Subscriber

Answer: ERCP is a procedure that utilizes endoscopy and fluoroscopy to visualize, examine, and diagnose stones, tumors, or narrowing in the bile or pancreatic ducts. For removal of stones, you’ll report 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with removal of calculi/debris from biliary/pancreatic duct[s]), often in conjunction with the code 43262 (Endoscopic retrograde cholangiopancreatography [ERCP]; with sphincterotomy/papillotomy).

Two commonly used devices for stone removal are a basket and a balloon. A catheter with a basket is passed over a guide wire into the duct and the basket traps the stone, which is then withdrawn into the duodenum and opened to release the stone. A balloon also can be used to dredge out the stones.

Watch out: The main mistake to avoid with this service is to code for multiple stones. The CPT^® definition of 43264 says “debris/calculi,” so it doesn’t matter how many stones were removed. You will also code the procedure once even if multiple methods are used in the same session for stone removal, or if the same or multiple balloon catheters are used multiple times to clear stones and debris from the ducts.

However, there’s a catch. Although you can report the use of a balloon to remove stones, you should not confuse that with the balloon dilation of the ampulla, biliary, or pancreatic ducts, which is a separate procedure reported with a 43277 (Endoscopic retrograde cholangiopancreatography [ERCP]; with trans-endoscopic balloon dilation of biliary/pancreatic duct[s] or of ampulla [sphincteroplasty], including sphincterotomy, when performed, each duct).

Although you cannot report 43277 for use of a balloon catheter to clear stones/debris from a duct, you can report code 43277 if sphincteroplasty or dilation of a ductal stricture is required before proceeding to remove stones/debris from the duct during the same session. So if the physician encounters a stricture of one of the ducts and uses a balloon for ductal dilation, you can report the procedure separately. Note that 43277 includes sphincterotomy, if performed.