Advanced Search

Gastroenterology Coding Alert

Reader Questions:

Report Observation if It Leads to ERCP

Published on Tue May 10, 2005

Question: One morning, our gastroenterologist admitted a patient to the hospital for observation because of abdominal pain. Based on the observation, the gastroenterologist performed an endoscopic retrograde cholangiopancreatography (ERCP) and removed a foreign object. The gastroenterologist then discharged the patient that afternoon. Can we report the observation and
ERCP separately?

South Carolina Subscriber
 
Answer: If the gastroenterologist decided during the observation that the patient should have the ERCP, then the observation is separately reportable.  Assuming the patient was admitted to observation and discharged on the same calendar day, you should also report 99234, 99235, or 99236 - depending on the level of service provided
 
For example, if your physician provided level-two  observation service before the ERCP, you would:
 

  •  report 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent) for the ERCP.
     
  •  report 99235 (Observation or inpatient hospital  care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making  of moderate complexity) for the observation.
     
  •  attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99235 to show that the observation and the ERCP were separate services.
     
  •  attach ICD-9 code 789.09 (Abdominal pain, generalized) to 43269 and 99235 to prove medical necessity for both services.

    Also: On the claim, be sure the documentation illustrates to the payer how the gastroenterologist's findings in observation led to the ERCP. Otherwise, the payer may consider the observation services to be part of the ERCP.

    • Other Articles in this issue of

    Gastroenterology Coding Alert

    View All