Wiki ERCP vs. EGD

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pamsbill

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I have a situation where the physician did an ERCP with sphincterotomy and stone removal. On the way out, he did a biopsy of the stomach for gastritis. He coded it 43264, 43262, 43261, which we billed.

The insurance company bundled the 43261 which we appealed and now they are stating we should have billed a 43239 instead of the 43261.

I have mixed feelings about this because, while I agree the biopsy was done in the stomach, the procedure performed was definitely an ERCP. To me, it is akin to doing a colonoscopy to the cecum, doing a biopsy in the sigmoid on the way out and being told we should bill a 45331 (flex sig w/biopsy.)

What do you guys think about this?
 
We bill out using ERCP codes unless the physician required withdrawing the ERCP scope and using an EGD scope for the bx. Then we bill out the appropriate ERCP cpt (stone extraction etc) and EGD bx cpt.
 
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coachlang3 said:
I would have billed the 43239.
Click to expand...

Talk to me coach - why not the ERCP? You don't think my analogy applies? I trust you but I need to understand the theory behind why, during an ERCP, when a biopsy is taken along the route, it would be billed as a lesser procedure.

Let's make the analogy a little closer to this situation: you do a colonoscopy, snare a polyp in the cecum and biopsy the sigmoid due to inflammation, are you going to bill a 45385 and a 45331? What's the difference?
 
Your analogy doesn't work here.

As long as the doctor gets past the splenic flexure it is a 4538x no matter where the specimens come from because you are still in the colon.

However, an ERCP is an examination of the hepatobiliary system. That does not include the gastric or esophogeal areas. You just go through those sites to get to the hepatobiliary site.
 
I am glad this topic came up. I had a similar situation recently, and went with the 43261. However, now that the topic is being discussed, I got out my Gastroenterology Surgery Coding manual. When I look at the "plain english" description of 43260-43261, it states this:
"...the common bile duct, biliary tract, gallbladder and pancreas are visualized on xrays....The catheter may be advanced over a guidewire into the common bile duct, biliary tract, gallbladder, and/or pancreas to collect cells from one or more of these sites. Use code 43261 when one or more tissue samples are taken". The description goes on to state that the esophagus, stomach are passed through to reach the Ampulla of Vater. Even the anatomical diagram of 43261 only shows the biliary system. After reading this more thoroughly, I'm inclined to go with the 43239 with the appropriate modifier, and plan to further discuss with the other coder in our Practice. Interested to see what others are doing!
 
Well, I guess then it is safe to say whatever is done in the anatomical regions outside of the the ducts is completely separate from what you do once you head into a duct. Anything done once you branch off into a duct is covered by the ERCP codes but everything else is covered by the codes for that specific part of the anatomy. I have to see if I can find any CPT Assistant guidance on this.
 
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