General Surgery Coding Alert

Sphincterotomy no longer separate.

Coding for stent placement, removal, or both via endoscopic retrograde cholangiopancreatography (ERCP) just got simpler.

Since Jan. 1, you’ve had three new, comprehensive CPT® 2014 codes to replace two deleted codes that you used in earlier years.

Let our experts show you how the CPT® 2014 changes will make your life easier when you try to report these general surgery procedures.

Tip 1: Drop the Old Codes

Before the CPT® 2014 changes, you’d report ERCP stent placement/removal using the following codes:

• 43268 — Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct
• 43269 — … with endoscopic retrograde removal of foreign body and/or change of tube or stent.

Using these codes, if your surgeon replaced multiple stents in one duct, you could report just one unit of 43268. You would bill for multiple units only if the surgeon placed stents in both the biliary and pancreatic duct.

If your surgeon replaced a stent, you would have reported 43269 for the service, prior to Jan. 1.

Notice: CPT® 2014 also deleted 43267 (… with endoscopic retrograde insertion of nasobiliary or nasopancreatic drainage tube).

Tip 2: Learn the New Codes

CPT® 2014 includes the following three new codes for ERCP stent placement/removal:

• 43274 — Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent
  
• Notice the new text note that directs you to 43274 for naso-biliary or naso-pancreatic drainage tube placement instead of deleted code 43267.
  
• 43275 — … with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s)
  
• 43276 — … with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged.
  

Per stent: Notice that you should list 43274 for each stent, even if they’re in the same duct. That’s different from the old codes, as discussed previously. CPT® instructs you to use modifier 59 (Distinct procedural service) for each subsequent stent placed.

Similarly, 43276 includes removal and replacement of one stent. “For replacement of additional stent(s) during the same session, report 43276 with modifier 59 for each additional replacement,” according to CPT® instruction.

Exception: Code 43275 represents removal of one or more stents during the same operative session.

Removal and placement: You’ll also notice that the deleted codes didn’t provide a way to distinguish the service of simply removing a stent versus removing and replacing a stent. But the new codes do.

The three new codes allow you to distinguish between “stent placement, stent removal, and removal/exchange of stents,” according to Joel V. Brill, MD, AGAF in his “Gastroenterology” presentation at the AMA CPT® and RBRVS 2014 Annual Symposium.

“The benefit is that the new codes will help you avoid the coding confusion of picking between one code for the replacement or two codes (one for the removal and another for the insertion),” says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel.

Tip 3: Know What’s Included

You can see by the definitions that the new codes 43274 and 43276 are comprehensive. They include pre- and post-dilation, guide wire passage, and sphincterotomy, when performed. You should still separately report radiology for these services, however

Old way: You used to report the comprehensive ERCP stent placement service with (now deleted) code 43268 for the stent, 43262 (… with sphincterotomy/papillotomy) for the sphincterotomy, and (now deleted) code 43271 (…with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct[s]) for the dilation. “Now you report the same service using 43274,” according to Brill in his presentation.

Caution: Use the ERCP codes only “if one or more of the ductal system(s) (pancreatic, biliary) is/are visualized. To report ERCP attempted by with unsuccessful cannulation of any ductal system, see 43235-43259),” according to the new CPT® 2014 ERCP introduction.

Tip 4: Check Out These Examples

Try your hand at coding these two scenarios using new codes 43274-43276.

Example 1: Your surgeon assesses a 53-year-old male patient with a history of biliary colic who presents with complaints of abdominal pain, nausea, vomiting, and diarrhea. Upon physical examination, the surgeon notes left and right upper abdominal tenderness, distension, fever, and some signs of jaundice. Suspecting biliary pancreatitis, the surgeon performs an ERCP and places a stent in the pancreatic duct. He performs a sphincterotomy and examines the biliary duct, performs lithotripsy for destruction of a stone that is occluding the duct, and places two stents in the biliary duct.

Solution 1: You should report the placement of the stents in the biliary duct with two units of 43274 and the placement of the stent in the pancreatic duct with another unit of 43274. Append modifier 59 for additional units of 43274, according to CPT® instruction. Since 43274 includes sphincterotomy, you should not separately report 43262. But the destruction of the stone is separate, and you should report it with 43265 (…with destruction, of calculi, any method [e.g., mechanical, electrohydraulic, lithotripsy]). Make sure you provide documentation to inform the payer that your clinician placed two stents in the biliary ducts and one in the pancreatic duct.

Example 2: The patient from example 1 comes back to your surgeon after a period of about two months with complaints of increasing pain and increasing signs of recurrent jaundice. The surgeon performs a second ERCP procedure to check for signs of occlusion of the stent.

During the procedure, the surgeon observes blockage of one of the stents that had been placed previously and removes the stent with a snare and then replaces it with another stent. He also observes the pancreatic stent but leaves it in place.

Solution 2: Report the replacement of the biliary stent with 43276. If the surgeon had only removed the stent and not replaced it with another stent, you would have reported 43275.