General Surgery Coding Alert

Question: How should we report an ERCP when the surgeon extracts a gallstone and performs a sphincterotomy? During the same operative session the surgeon also biopsies an ulcer in the stomach.

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Answer: You can report multiple codes for the distinct services that this surgical case encompasses.

For the endoscopic retrograde cholangiopancreatography (ERCP) with removal of a gallstone, you should report 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts).

You can additionally report the sphincterotomy using 43262 (…with sphincterotomy/papillotomy). In fact, a new text note following 43262 in CPT® 2014 states, “43262 may be reported when sphincterotomy is performed in addition to 43261, 43263, 43264, 43265, 43275, 43278.”

Assuming the surgeon proceeds endoscopically for the stomach ulcer biopsy, you should report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) in addition to the other two codes. When the surgeon performs a procedure outside of the ducts involved in the ERCP, you can report it as a separate service.

There’s not a Correct Coding Initiative (CCI) edit that bundles these codes, so you won’t need modifier 59 (Distinct procedural service) to report them together. Although some payers still require modifier 51 (Multiple procedures) in circumstances such as this case, Medicare and many other payers no longer require this “informational” modifier.