General Surgery Coding Alert

Question: The patient had a 7 French stent. Our general surgeon performed an ERCP to remove the stent and replace it with a 10 French x 9 cm, with decompression of the biliary tree in standard fashion. Should I report 43268 and 43269-59?

Kansas Subscriber

Answer: No, what you suggest is not proper coding.

Because a stent was already in place when the surgeon began the procedure, you would be justified in reporting 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent).

However, reporting 43269 with 43268 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) for the procedure you describe is problematic.

First: Code 43269 includes “change of … stent,” which implies removal of an existing stent and replacement with a new stent — which is exactly what your surgeon performs.

Second: Medicare’s Correct Coding Initiative (CCI) lists the stent placement (43268) and removal (43269) codes as mutually exclusive, which means they cannot be “reasonably done in the same session.”

Although CCI allows the use of a modifier to override this edit pair, you don’t appear to have justification, such as different operative session or different site or incision, to do so. Even if you had such documentation, you would need to append the modifier, such as 59 (Distinct procedural service) to the column 2 code, which is 43268, not the column 1 code (43269).