Gastroenterology Coding Alert

Question: How should I report an ERCP (endoscopic retrograde cholangiopancreatography) with stent placement and injection therapy for control of bleed? The operative report reads that "there was mild oozing at the papillotomy and this was injected with 2.5 cm of epinephrine to control the oozing. The pancreatic duct was not injected." This is a post-liver transplant patient with anastomotic bile structure. Michigan Subscriber Answer: The ERCP with stent placement is reported with 43268. Whether you can separately report the injection therapy for the control of bleeding depends on what caused the bleeding. The bleeding is most likely a result of the papillotomy (a surgical incision made at the papilla of Vater, also referred to as a sphincterotomy) performed by your gastroenterologist. In that case, you cannot bill separately for the injection therapy because Medicare and most private insurers have a you-break-it-you-fix-it policy. "When a complication described by codes defining complications arises during an operative session, however, it is incorrect to report a separate service for treating such complications," states the national Correct Coding Policy Manual for Medicare Part B Carriers (also known as the Correct Coding Initiative [CCI]). If the bleeding was not caused by the incision, you can bill the injection therapy with EGD with control-of-bleeding code 43255 because there is no code for ERCP with control of bleeding code. The endoscope used for the injection therapy will follow basically the same route that it would with an EGD. Code 43255 is not bundled with the ERCP with stent placement code 43268 in the CCI, but you may want to attach either modifier -51 (Multiple procedures) or -59 (Distinct procedural service) (depending on your payer requirements) to the control-of-bleeding code to indicate that it is a separate and distinct procedure.

If the gastroenterologist performed the papillotomy (sphincterotomy) during this same session, that service can be billed separately with 43262.