General Surgery Coding Alert

Update your dilation and ablation codes, too.

With plenty of new, deleted, and modified codes in place this year, you have a lot to learn to round out your 2014 endoscopic retrograde cholangiopancreatography (ERCP) coding know how. 

Here’s a run-down of more code changes you’ll need to know in addition to those discussed last month in “4 Tips Update ERCP Stent Coding” in General Surgery Coding Alert Vol. 16 No. 3.

Bundle Up Balloon Dilation

You’ll need to learn some new tricks to manage coding for ERCP services that involve balloon dilation. CPT® 2014 deletes 43271 (Endoscopic Retrograde Cholangiopancreatography [ERCP]; with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct[s]) and 43272 (… with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) and replaces them with the following two new codes, respectively:

• 43277 — Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct 
  You may separately report 43277 “if sphincteroplasty or dilation of a ductal stricture is required before proceeding to remove stones/debris from the duct during the same session,” according to CPT® instruction.
• 43278 — …with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed.

Inclusive: Unlike the deleted codes but similar to new codes 43274-43276 discussed in “4 Tips Update ERCP Stent Coding,” new codes 43277-73278 are comprehensive codes that include additional listed services, such as sphincterotomy for 43277 and dilation/guide wire passage for 43278.

Per duct: Another important change you’ll notice with the conversion from 43271 to 43277 is that you should report balloon dilation per duct in 2014. “The 43271 wording, ‘biliary and/or pancreatic duct[s]’ implied one unit, even if your surgeon dilated the biliary and pancreatic duct,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, internal audit manager at CHAN Healthcare in Vancouver, Wash.

Stand alone: You used to use the now deleted balloon dilation codes (such as 43271) in addition to other now deleted ERCP codes such as 43268(Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) when the surgeon performed both services. But CPT® 2014 adds new, comprehensive codes that bundle all the steps into one. “Now you report the same service using 43274 [...with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent],” according to Joel V. Brill, MD, AGAF in his “Gastroenterology” presentation at the AMA CPT® and RBRVS 2014 Annual Symposium.

Check Out These Code Changes

In addition to adding and deleting ERCP codes, CPT® 2014 revises the following four ERCP codes and adds text notes as follows, with important additions underlined and deletions shown with strikethrough:

• 43260 — … diagnostic, with or without including collection of specimen(s) by brushing or washing, when performed (separate procedure)
• 43263 — … with pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct)
• 43264 — … with endoscopic retrograde removal of calculus calculi/debris from biliary/pancreatic duct(s)
• 43265 — … with endoscopic retrograde destruction lithotripsy of calculi, any method (e.g., mechanical, electrohydraulic, lithotripsy).

Most of these represent minor changes in wording for clarity that won’t change how you use these codes.

Exception: 43264 now allows you to use the code for removing debris, not just calculi. 

To use these revised codes correctly, you should also heed the following new introduction and text notes in CPT® 2014: 

• Therapeutic ERCP includes diagnostic ERCP (43260)
• Do not report 43263 more than once per session
• Do not report 43264 or 43265 if no calculi or debris are found, even if balloon catheter is deployed
• Do not report 43265 in conjunction with 43264
• Do not report 43277 for use of a balloon catheter to clear stones/debris from a duct. Any dilation of the duct that may occur during this maneuver is considered inherent to the work of 43264 and 43265.
• Use 43262 when performing sphincterotomy in addition to 43261, 43263, 43264, 43265, 43275, 43278.