Outpatient Facility Coding Alert

Break down each coding solution, from stone removal to ERCP.

Depending on your ambulatory surgical center (ASC) or outpatient facility’s primary specialty, you might code a frequent amount of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Coding these procedures can prove challenging to coders of all skill levels — and you need a clear understanding of the 43260-43278 code range to do so.

Context:  ERCP involves using an endoscope and fluoroscopy to examine the ducts that drain the liver and pancreas. Endoscopists often use ERCP to treat conditions such as choledocholithiasis (bile stones), tumors, strictures (scarring and narrowing), pancreatic cysts, pancreatitis, and necrosis. For that reason, the procedure frequently includes performing therapeutic actions such as stone removal, lithotripsy, stent placement, tumor excision, balloon dilation, etc.

A number of changes have occurred in this family of [procedure] codes over the past few years. With a multitude of procedures and code options, you cannot afford to let your guard down as far as accuracy is concerned, says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, New Jersey.

Read on for an overview of the ERCP treatment options, and how to tackle coding conundrums in each case.

Focus Stone-Removal Coding

If your surgeon removes stones from the pancreatic or biliary duct, you should use CPT^® code 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with removal of calculi/debris from biliary/pancreatic duct[s]).

The procedure: The surgeon will pass a guidewire and catheter into the duct(s), and remove stone(s). The method might include using a basket over the guidewire to trap the stone, then withdrawing the catheter into the duodenum to release the stone. The surgeon may also pass a balloon over a guidewire to dredge out the stones. If the surgeon doesn’t succeed in identifying and removing any calculi or debris, don’t report 43264.

Remember: The method(s) or number of stones does not impact coding — report 43264 only once for any number of stones, even if the surgeon used multiple removal methods in the same session.

Limitations: According to AMA, you should not report 43264 with the following codes:

• 43260 — … diagnostic, including collection of specimen[s] by brushing or washing, when performed (separate procedure)
• 43265 —… with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy).

Because both CPT^® instruction and National Correct Coding Initiative (NCCI) edits restrict reporting together 43264 and 43265, you should bill only the column 1 code, 43265, which, according to the July Addendum AA ASC rate pays $1848.57 compared to pay for 43264 ($1,212.00).

Opportunity: If your surgeon used extracorporeal shock wave lithotripsy (ESWL) to fragment the stones, you may use 47999 (Unlisted procedure, biliary tract) or 48999 (Unlisted procedure, pancreas) to report lithotripsy as a separate procedure. Because this is an unlisted code, make sure to back up the claim with a copy of the operative report and a detailed description of the procedure. Also, be sure to check payer policy for additional or alternative guidance.

Tackle ERCP With Sphincterotomy

If the surgeon identifies a bile duct blockage during ERCP that requires cutting a portion of the ring-like muscle to create a sphincterotomy, you should report 43262 (… with sphincterotomy/papillotomy).

Beware of bundles: If your provider places or removes stents in the biliary or pancreatic duct, the procedure code includes sphincterotomy. That means you should not report 43262 with the following codes:

• 43274 — … 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
• 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.

Capture additional procedures: On the other hand, there are several procedures that you can report in addition to the sphincterotomy if the surgeon performs the service. For instance, you can report 43262 with additional code(s) for the following procedures:

• biopsy (43261 […  with biopsy, single or multiple])
• pressure measurement (43263 […with pressure measurement of sphincter of Oddi])
• calculi/debris calculi removal (43264 […with removal of calculi/debris from biliary/pancreatic duct(s)]
• calculi destruction (43265, [… with destruction of calculi, any method (eg, mechanical, electrohy­draulic, lithotripsy)])
• lesion removal/ablation (43278 [… with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed]).

Distinguish sphincteroplasty: Sphincteroplasty means enlarging a blocked duct or the sphincter using endoscopic balloon dilation. Dilation of the ampulla, biliary, or pancreatic ducts, is a separate procedure with a distinct CPT^® code: 43277 (… with trans-endoscopic balloon dilation of biliary/pancreatic duct[s] or of ampulla [sphincteroplasty], including sphincterotomy, when performed, each duct). You can report code 43277 for a sphincteroplasty or dilation of a ductal stricture.

Use Modifiers for Multiple Procedures

If the surgeon performs two ERCP procedures that aren’t limited by CPT^® rules or NCCI edits, you can bill both services and expect adjusted payment for both procedures. The payer will reimburse the full fee-schedule amount of the higher-valued code, and reduce the payment for the second procedure by the parent-code value. Most payers don’t want you to use modifier 51 (Multiple procedures) to identify these cases but will automatically adjust payments for multiple procedures.

Remember: The above refers to physician billing only, not ASCs or outpatient facilities.

Bundled codes: If the surgeon documents two separate ERCP procedures described by bundled codes, you might be able to override the edits with by appending modifier 59 (Distinct procedural service) to the column 2 code — but not if CCI lists the edit pair with modifier indicator of “0.”

For instance: If the surgeon performs lithotripsy for calculi in the biliary duct, and during the same ERCP session, performs a balloon dilation of the pancreatic duct, you can report 43265 and 43277-59.

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