Even though an incomplete endoscopic retrograde cholangiopancreatography (ERCP) can take a long time, there is no policy from either CPT or Medicare on how to report one. Lacking national guidelines, many
gastroenterology practices have developed their own methods for coding these procedures, some of which may not ethically maximize their reimbursement dollars.
The lack of a coding policy makes it difficult even to determine a complete and an incomplete ERCP. Most ERCPs are not finished due to the gastroenterologist's inability to cannulate the ampulla of Vater because it's blocked or can't be found. However, a blockage further up in the patient's esophagus may also cause the procedure to be terminated, or the sedation could wear off on a patient, causing him or her to become combative.
"What makes this such a difficult issue is that there is no policy to tell you how far the endoscope has to advance like there is with a colonoscopy," says Barb Kallas, billing specialist for Gastroenterology Consultants, a practice with 10 gastroenterologists in Milwaukee.
Indeed, the AMA's CPT states that an endoscope must advance past the splenic flexure to be considered a complete colonoscopy. If the endoscope does not advance past that point, the procedure is considered a flexible sigmoidoscopy regardless of the fact that a colonoscope is used instead of a sigmoidoscope. In addition, Medicare has a national policy for billing incomplete colonoscopies by attaching modifier -53 (Discontinued procedure) to diagnostic colonoscopy code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]). Medicare's Physician Fee Schedule database even has an established relative value unit (RVU) for 45378-53.
Kallas adds, "With an EGD [esophagogastroduodenoscopy], you are also told how far the scope has to advance or else it's not an EGD."
Although there isn't a specific policy for reporting an incomplete EGD, the CPT definition for the procedure makes it clear that the endoscope must advance beyond the patient's stomach and into either the duodenum or the jejunum to bill EGD code 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). If the endoscope does not advance to the duodenum or the jejunum, the esophagoscopy code 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) must be billed instead.
Incomplete If No Cannulation
There is nothing in writing from either CPT or Medicare as to what constitutes a complete ERCP. Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, uses a definition provided by the medical coding publisher Medicode. "In [...]
