Gastroenterology Coding Alert

One of the golden rules of coding for gastroenterology used to be that an endoscopic retrograde cholangiopancreatography (ERCP) and an upper gastrointestinal endoscopy (EGD) performed during the same session could not be billed separately because they were bundled together in the Correct Coding Initiative (CCI) edits. While Medicare has removed many of these ERCP-EGD edits, some gastroenterology practices are losing reimbursement by continuing to bill these procedures as if the edits still exist. Even ERCP-EGD combinations that are still bundled together in the CCI may be overridden with the proper modifier if the two procedures are separate and distinct.
 
"I was always told to never bill an ERCP and EGD procedure together because they were bundled," says Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 23-physician practice. "But if you look at the CCI edits, some of those have been changed."
Scopes Are Key to Correct Coding  
Coders must understand the differences between these two endoscopic procedures, which both involve passing a scope through the esophagus to the duodenum, to code them appropriately. An EGD is done to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting or difficulty swallowing. It detects upper gastrointestinal bleeding, ulcers and strictures.
 
An ERCP, on the other hand, is for a different set of medical indications. The procedure evaluates and visualizes the hepatobiliary system, which includes the pancreatic ducts, hepatic ducts, common bile ducts, duodenal papilla (also known as the ampulla of Vater) and the gallbladder. A side-viewing endoscope (also referred to as a duodenoscope) is passed orally into the duodenum, where a cannula or hollow tube is inserted into the major papilla and injected with contrast material that allows the gastroenterologist to see the entire hepatobiliary system with the aid of a fluoroscope.
 
ERCPs are commonly used to investigate elevated liver lab tests and to diagnose and treat conditions of the bile duct and pancreas including gallstones, sclerosing cholangitis, and pancreatic cancer, says Sarkis J. Chobanian, MD, FACP, FACG, a gastroenterologist in Knoxville, Tenn.
 
Another way to distinguish between the two procedures is through the different scopes that are used for each. For an EGD, the gastroenterologist will use a traditional endoscope -- a long, thin, flexible tube with a tiny video camera and light at the end. During an ERCP, the side-viewing duodenoscope will be used. The two scopes are not interchangeable in terms of function because even though it passes through the esophagus, the duodenoscope doesn't give the gastroenterologist a good view of the esophagus, Chobanian says.
 
One of the most common ERCP-EGD coding combinations is an ERCP procedure performed during the same session as an EGD with biopsy. "A patient may have the symptoms of an ulcer and [...]