CPT® 2016: Percutaneous Biliary Interventional Coding
Part 2: New codes change the way you should report these procedures.
For 2016, the biggest CPT® coding changes affecting interventional radiology occur within the subspecialties of urinary, biliary, and neurologic intervention. In March, we covered urinary intervention. This month, we’ll discuss the major changes in percutaneous biliary interventional coding. Next month, we’ll cover CPT® updates for percutaneous neurologic intervention.
The biliary system is divided into right- and left-sided bile ducts; however, these ducts divide further into multiple smaller branches that may be individually accessed and drained, depending on the pathology treated (e.g., Klatskin tumor is a cholangiocarcinoma that has involved and caused bifurcation occlusions of the common bile duct. As it grows further, it may compromise additional ducts requiring three or four catheters for successful drainage). Terminology for biliary procedures refers to either “catheters” (which are externally accessible, such as an internal/external biliary drainage catheter) or “stents” (which are not externally accessible, such as a metallic biliary stent).
New Codes for 2016
There are 14 new biliary intervention codes for 2016 (see “New Biliary Intervention Codes for 2016″). These codes include both the surgical and supervision and interpretation (S&I) components of the procedure. As well, all of the new codes bundle the use of imaging guidance, including fluoroscopy, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI).
CPT® guidelines instruct us to code separately for each catheter placement, replacement, conversion, or removal. Catheter procedure codes are based on each individual catheter via a separate access site.
Here’s a rundown of how to apply the new codes.
Cholangiography (47532 and 47531) is performed to evaluate the biliary system for patency, stones, strictures, malignancy, and leaks. These abnormalities can occur anywhere in the collecting system, but most often are between the ampullary sphincter of the distal common bile duct and the bifurcation of the more proximal common bile duct.
The cholangiogram may be performed via a new access (placing a needle or catheter through the right side or anterior abdominal wall into the right or left bile ducts respectively) or via a pre-existing catheter, usually an existing biliary catheter. Contrast is injected and imaging is performed and interpreted. The procedure is reported with 47532 when performed via a new access, or with 47531 when performed via an existing access. Because imaging guidance is performed, be sure the ultrasound, CT, or MRI tech does not charge a guidance code when the access uses one of these imaging guidance modalities.
Cholangiography is bundled with the new external biliary catheter, internal/external catheter, and biliary stent placement codes. The cholangiogram codes may be used as a base code for +47542, +47543, and +47544, but only if a catheter is not placed, replaced, or converted.
Example: A patient has an existing external biliary drainage catheter. Diagnostic cholangiogram is performed (47531), demonstrating a distal common bile duct stenosis. Cholangioplasty is performed (+47542). No tubes are left in place at the end of the procedure (add 47537 for tube removal, delete 47531 as bundled with tube removal).
The following codes involve placement of an external or internal/external biliary drainage catheter:
47533 describes the initial placement of a percutaneous external biliary drainage catheter via a new access, and includes diagnostic imaging 47532. Submit 47533 once for each external biliary drainage catheter placed via a new access at the same session.
47534 describes the initial placement of a percutaneous internal/external biliary drainage catheter via a new access, and includes diagnostic imaging 47532. Submit 47534 once for each internal/external biliary drainage catheter placed via a new access at the same session.
47535 describes the conversion of an existing external biliary drainage catheter to an internal/external catheter (removal of the external catheter and placement of the internal/external catheter over a wire, which requires crossing of the distal common bile duct into the small intestine), and includes diagnostic imaging. Submit 47535 once for each biliary catheter conversion at the same session.
47536 describes the exchange of an existing external biliary drainage catheter/external biliary drainage catheter or exchange of an existing internal/external catheter for a lesser external catheter, and includes diagnostic imaging. Submit 47536 for each catheter exchanged at the same session.
47537 describes the removal of an existing external or internal/external biliary drainage catheter, and includes diagnostic imaging. Submit 47537 once for each catheter removed at the same session.
Example: The patient recently underwent external biliary drainage catheter placement for biliary obstruction and infection. Now that the infection has subsided, a diagnostic cholangiogram is performed, showing distal common bile stenosis. The external biliary catheter is removed over a wire and an internal/external catheter is advanced with the distal tip in the small intestine and secured in position (Add 47535 for the conversion of an external catheter to an internal/external catheter. Do not report 47531, as it’s bundled with this conversion).
Initial Biliary Stent Placements
There are three new codes for initial biliary stent placements. The codes differentiate existing access from new access:
47538 describes the placement of a completely internal stent (metallic or plastic) via an existing access (prior external biliary catheter or internal/external biliary catheter access) and includes exchange of an existing externally draining biliary catheter (if done); down-conversion to an external catheter (when the original catheter is an internal/external catheter); or removal of a catheter at the end of the procedure. Do not submit 47536 or 47537 with this procedure.
47539 describes the placement of a completely internal stent via a new access without leaving a biliary catheter at the end of the procedure.
47540 describes the placement of a completely internal stent via a new access with separate placement of an external or internal/external biliary catheter. Do not submit 47533 or 47534 with this procedure.
All three codes include an initial cholangiogram (47532, 47531) and all imaging guidance (e.g., fluoroscopy, ultrasound, CT, MRI). Two stent codes can be submitted when “double-barrel,” or side-by-side, stents are placed for the treatment of a single stenosis (usually in the common bile duct from two approaches), when two separate accesses are used to place two stents, and when two stents are placed into two bile ducts for treatment of two separate stenoses. The stent codes may be used more than two times in individuals requiring multiple stents to treat multiple stenoses in different ducts. If multiple overlapping stents are placed via a single access, only one stent procedure code is submitted. Cholangioplasty is bundled when performed at the same site as a biliary stent deployment.
Example: A patient with an existing external biliary catheter presents for conversion to an internalized metallic biliary stent (47538). At the end of the procedure, a new external biliary drainage catheter is placed over the guidewire due to excessive bleeding during the procedure (This is bundled with internal biliary stent placement.).
New Code for “Rendezvous” Procedure
Code 47541 describes the creation of an access into the biliary system for subsequent use by an endoscopist. The radiologist will create a new access into a bile duct and advance a wire and small catheter across the biliary system and ampulla into the small intestine. The catheter and wire are secured in position and sent to endoscopy, where the gastroenterologist advances an endoscope into the duodenum, snares the wire, and uses this wire to advance a stent or balloon to complete that portion of the procedure. A cholangioplasty or stent placement by the radiologist can be submitted separately.
If the radiologist leaves in a drainage catheter, 47533 or 47534 should be submitted instead of 47541. Do not submit 47541 when a pre-existing catheter is accessed to perform the rendezvous procedure. When done via an existing access, submit a code describing a catheter exchange, removal, or conversion (e.g., 47535-47537).
New Add-on Codes
Codes +47542, +47543, and +47544 require a base code, which can be any of the catheter placement, conversion, or exchange codes, as well as diagnostic cholangiogram codes 47532 and 47531.
+47542 describes cholangioplasty (balloon dilation) of any bile duct for treatment of a stenosis or occlusion, and can also be used to report balloon dilation of the ampullary sphincter (sphincteroplasty) for subsequent stone extraction. Submit +47542 once per treatment site, for a maximum of two sites treated per session.
If more than two separate sites are treated with balloon dilation, no additional codes are submitted for the additional cholangioplasties. This may limit the number of cholangioplasties submitted in patients with sclerosing cholangitis. This limitation does not apply to stent placements.
Cholangioplasty at the site of a stent placement during the same session is bundled and not separately coded. Because of add-on code edits, it may not be possible to submit +47542 with a biliary stent code (47538-47540), even when done in different ducts. Do not use this code when a balloon catheter is used for stone extraction.
+47543 describes an endoluminal biopsy (brush, needle, or alligator forceps) of the biliary ductal system (common bile duct, intrahepatic bile ducts). If multiple bile ducts are biopsied, do not report additional procedure codes because all ducts biopsied are described by using this single code. Submit +47543 only once per date of service.
+47544 describes percutaneous biliary stone extraction by any method, and includes removal of stone(s) with a basket and/or pushed through the ampulla with a balloon. Do not use this code for removal of debris or sludge, and do not use it with an attempted procedure modifier if stone retrieval is attempted, but no stones are identified. Use this code only once per session.
A catheter placement, replacement, conversion, or removal code can additionally be submitted if done. An imaging code (47531 or 47532) can be submitted instead if the above catheter codes are not performed. Code +47544 may be used for stone extraction from the gall bladder via a cholecystostomy tube.
The three add-on procedure codes vary in the number of times each code can be submitted per day, and depend on access sites/approaches, location, and extent of the lesions treated and the specific limitations on the codes submitted.
Example: The patient has an internal/external catheter in place via a left anterior duct approach. The patient has a known filling defect in the region of the distal common bile duct, and is here for biopsy. The catheter is removed over a guidewire and a sheath is placed up to the abnormality. A brush biopsy followed by alligator forceps biopsy are performed and sent for pathology (+47543). A new internal/external stent is placed over the wire (exchange of biliary drainage catheter, 47536).
Same Old Code May Be Used with New Codes
Percutaneous cholecystostomy, which includes placement of a drainage catheter into the gallbladder (47490 Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation), remains unchanged in 2016. This procedure may be reported with new codes for tube check (47531), tube change (47536), tube removal (47537), and stone extraction (47544).
With the new codes added in 2016, a comprehensive set of biliary codes is now available to describe almost every procedure performed in the biliary system. The opportunity for coding specificity has never been better.
New Biliary Intervention Codes for 2016
47531 Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; existing access
47532 new access (eg, percutaneous transhepatic cholangiogram)
Percutaneous biliary drainage catheters
47533 Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; external
47535 Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation
47536 Exchange of biliary drainage catheter (eg, external, internal-external, or conversion of internal-external to external only), percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation
47537 Removal of biliary drainage catheter, percutaneous, requiring fluoroscopic guidance (eg, with concurrent indwelling biliary stents), including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation
Percutaneous biliary stent placements
47538 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; existing access
47539 new access, without placement of separate biliary drainage catheter
47540 new access, with placement of separate biliary drainage catheter (eg, external or internal-external)
Three add-on procedures:
cholangioplasty, biopsy, and stone extraction
+47542 Balloon dilation of biliary duct(s) or of ampulla (sphincteroplasty), percutaneous, including imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation, each duct (List separately in addition to code for primary procedure)
+47543 Endoluminal biopsy(ies) of biliary tree, percutaneous, any method(s) (eg, brush, forceps, and/or needle), including imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation, single or multiple (List separately in addition to code for primary procedure)
+47544 Removal of calculi/debris from biliary duct(s) and/or gallbladder, percutaneous, including destruction of calculi by any method (eg, mechanical, electrohydraulic, lithotripsy) when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)
Access placement to assist with endoscopic biliary procedure
47541 Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary procedure (eg, rendezvous procedure), percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation, new access
Deleted and Revised Biliary Codes
Twelve biliary CPT® codes were deleted for 2016 (47500, 47505, 47510, 47511, 47525, 47530, 47630, 74305, 74320, 74327, 75980, and 75982), and five previously recommended “endoscopic” codes (47552, 47553, 47554, 47555, and 47556) should no longer be used for percutaneous procedures because new codes more accurately describe these procedures.
David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC, or Dr. Z, is the founder and CEO of ZHealth, LLC, and ZHealth Publishing, LLC. He practiced as an interventional radiologist for 15 years and has 16 years of experience as a coding reviewer and educator. Dr. Z is Board Certified in Radiology with the Certification of Added Qualification (CAQ) in Interventional Radiology (ABR) (1995, 2005). He was on the AAPC National Advisory Board from 2005-2009, and is a member of the Nashville, Tenn., local chapter.