Primary Care Coding Alert

Question: One of our physicians changes the stent in his patients and wants to bill using 43268 and 43269. He thinks we should be able to bill 43268 for removing the stent and 43269 for inserting a new one. But Medicare is denying the charges for 43268 when used with 43269. Is there a better way to code for an ERCP stent change?

Eileen Gaines
UCSF Department of Medicine, San Francisco

Answer: The problems you are encountering are caused by the current Medicare Fee Schedule. This fee schedule was implemented because it had become increasingly important to assure that all carriers followed uniform payment policies and procedures. The rationale is that when the same service is rendered in various carrier jurisdictions, it is paid for in the same way. Therefore, the National Correct Coding Council was contracted to develop correct coding methodologies to control improper coding that leads to inappropriate and increased payment. They devised a manual for National Correct Coding Policy and Edits, which is divided into two sections: a) mutually exclusive procedures and b) comprehensive and component procedures.

Mutually exclusive procedures are those that cannot be performed during the same operative session. Comprehensive and component procedure codes will not be reimbursed when the component procedure is rendered by the same provider on the same date of service as the comprehensive procedure.

Codes 43268 (endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) and 43269 (endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent) are mutually exclusive, and therefore cannot be performed during the same operative session. Code 43269 is the appropriate code to bill for the service because, by definition, it clearly describes the service your physician performed.

Code 43269 may have a lower reimbursement level than 43268 because more skill and risk is involved with the initial placement of a stent as opposed to the replacement of an existing one.