General Surgery Coding Alert

Code per session, not per stent.

In the massive code overhaul of percutaneous biliary procedures for 2016, reporting stents stands out as one of the most confusing areas you’ll need to tackle.

Let our experts walk you through four steps to make sure you choose the correct code, capture any multiple services you’re due, and avoid wrongly billing included procedures.

Tip 1: Send Out the Old, Bring In the New

You used to have one code to report percutaneous biliary stents — 47511 (Introduction of percutaneous transhepatic stent for internal and external biliary drainage) — but no more.

CPT^® 2016 deletes 47511 and replaces it with the following three codes:

• 47538 — Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (e.g., fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; existing access
• 47539 — … new access, without placement of separate biliary drainage catheter
• 47540 — … new access, with placement of separate biliary drainage catheter (e.g., external or internal-external)

To choose between these codes, you “need to know if it’s a new access or going through a tube already in place,” according to AMA CPT^® editorial panel member Katharine L. Krol, MD, FSIR, FACR at the AMA’s CPT^® and RBRVS 2016 Annual Symposium. That allows you to choose between 47538 for existing access, or one of the other codes for de novo access.

You should also answer the question, “Is the cath left in place afterwards or did we just put a stent in and then abandon access?” according to Krol. That allows you to choose between 47539 and 47540.

Tip 2: Distinguish ‘Catheter’ and ‘Stent

Your surgeon may use the words “catheter” and “stent” somewhat interchangeably, but the biliary CPT^® codes have a specific use for each of these words that you need to know.

“The biliary stent can have a couple of different configurations,” Krol says. “You can have stents that look like stents you put in a blood vessel,” such as metallic expanding stents. Or you may have plastic “catheter types that are all internal, and those are also called stents and reported with stent codes as defined by CPT^®,” according to Krol.

On the other hand, percutaneous biliary catheters always have external accessibility for drainage. “It can be either an external biliary drain or an inter-anal-external biliary drain, but the point is that the catheter sticks out of the patient,” Krol says. You should not report percutaneous biliary catheter procedures with the stent codes, but should turn instead to new codes 47533-47537 (…biliary drainage catheter …).

Key: Stents are “totally internal, not externally accessible,” Krol emphasizes. Even if the op report calls a catheter with an external drain a stent, you should not use the stent codes.

Tip 3: Focus Units of Service

Prepare to be confused. The CPT^® 2016 introduction to the percutaneous biliary procedures section does not agree with the new stent code definitions.

“One thing about the stent codes that I noticed is that the code nomenclature still says ‘each stent,’ but there is a lot of introductory language telling you that isn’t the case,” Krol says.

The CPT^® section introduction states, “Codes 47538, 47539, 47540 may be reported only once per session to describe one or more overlapping or serial stent(s) placed within a single bile duct, or bridging more than one ductal segment (e.g., left hepatic duct and common bile duct) through a single percutaneous access.”

In other words, the unit of service “is not each stent,” Krol says. For the most part, you should report these codes once per session for a single bile duct or a single lesion that crosses more than one bile duct, if the surgeon used a single percutaneous access. 

Caveat: Sometimes you can report multiple percutaneous biliary stent codes for the same patient on the same day, such as the following circumstances:

• Surgeon places side-by-side stents in a single bile duct (double barrel)
• Surgeon places two or more stents into separate bile ducts, but uses a single percutaneous access
• Surgeon places stents through multiple percutaneous access sites.

Do this: If your surgeon documents one of these conditions, you can report multiple stent codes for a single session and append modifier 59 (Distinct procedural service) or similar modifier to the additional stent codes.

Tip 4: Learn Bundling Restrictions

One of the primary reasons for this section update in CPT^® 2016 is to bundle imaging services with the surgical procedures. That means all of the new percutaneous biliary procedure codes, including 47538-47540, incorporate imaging guidance such as fluoroscopy or ultrasound, and radiological supervision and interpretation (S&I). The procedures also include diagnostic cholangiography, balloon dilation, and catheter exchange or removal, if performed.

That leads to a host of code bundles that CPT^® notes in the text, such as the following:

• Do not report 47538 in conjunction with 47536 (Exchange of biliary drainage catheter …percutaneous …), 47537 (Removal of biliary drainage catheter, percutaneous …) for the same percutaneous access
• Do not report 47538, 47539, 47540 in conjunction with 47542 (Balloon dilation of biliary duct[s] … percutaneous…)

Nor should you report the percutaneous stent codes with codes for similar procedures through the same access, or biliary procedures that utilize a different approach, such as endoscopic. That’s why CPT^® provides the following notes:

• Do not report 47538, 47539, 47540 in conjunction with 43277 (Endoscopic retrograde cholangiopancreatography [ERCP]…), 47555 or 47556 (Biliary endoscopy, percutaneous …), for the same lesion in the same session
• Do not report 47540 in conjunction with 47533 and 47534 (Placement of biliary drainage catheter, percutaneous …) for the same percutaneous access.