You Be the Coder:
Two ERCPs on Same Day
Published on Tue Jan 01, 2002
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: How should I code an attempted endoscopic retrograde cholangiopancreatography (ERCP) that was discontinued because the anatomy of the biliary tree made cannulation impossible. The gastroenterologist sent the patient to radiology and had a percutaneous trans-hepatic cholangiogram (PTC) catheter placed by the radiologist. After that, he was able to perform an ERCP with sphincterotomy and stent placement. He then removed the PTC catheter placed by the radiologist.
New York Subscriber
Answer: The ERCP with sphincterotomy with stent placement would be billed with 43262 (sphincterotomy) and 43268 (stent placement). Modifier -51 (multiple procedures) or -59 (distinct procedural service) (depending on your payer's requirements) may be added to either code to indicate that these are separate and distinct procedures. Because these codes are not bundled in the Correct Coding Initiative (CCI) and the Medicare relative value units for 2002 for these procedures are the same, it doesn't make any difference which code gets the modifier.
Most payers will automatically deny a claim with the same service listed twice in one calendar day as a duplicate. To try to recoup some reimbursement for the attempted ERCP, this is one time when it might be best to attach modifier -22 (unusual procedural services) to 43262 or 43268 and raise the fee for the completed procedure. You will have to attach a separate statement explaining how the service differs from the usual and also attach an operative report with the claim. The extra documentation should indicate the unusual difficulty of the case, and it may be helpful to note the amount of time the case took. Although claims with modifier -22 may be rejected more often than they are reimbursed, you probably have a good chance at getting increased reimbursement here.
A discontinued ERCP is not usually reported with modifier -22. Many gastroenterologists will bill an EGD (43235) when they have a discontinued ERCP. Here, however, you would then be reporting an EGD and ERCP on the same day, and those two codes are bundled together in CCI. In that situation, most payers will reimburse only for the lesser-valued EGD procedure, which has a significantly lower value than the ERCP.
Another option for billing a discontinued ERCP is to attach modifier -53 (discontinued procedure) to ERCP code 43260. But if you bill the discontinued ERCP and ERCP with sphincterotomy and stent placement on the same day, your payer will probably get very confused and reject the entire claim.
There is no separate reimbursement for removing the PTC catheter.
