Important CPT codes to remember while coding ERCP procedure

Basics Endoscopic Retrograde Cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that enables the physician to diagnose and treat problems involving the liver, gallbladder, bile ducts and pancreas. ERCP can be used to determine whether or not further surgery is necessary. A scope is passed through the mouth into the stomach and the duodenum. In the duodenum, the ampulla is identified and a cannula is passed through the endoscope and into the ampulla. Dye is then injected and X-rays are taken. If indicated, additional treatments such as gallstone removal, stent insertion or biopsy can be performed at this time.

Documentation required for coding ERCP Procedure

The history and physical examination should provide information defining the reason for the ERCP. Severe upper abdominal pain or discomfort, jaundice and/or weight loss are indications of hepatobiliary disease that may warrant an ERCP.
X-ray Findings: Presence of bile duct stones, cancerous and non-cancerous tumor(s), complications from previous gallbladder surgery (e.g., retained stone in the bile duct or Sphincter of Oddi dysfunction).

The final note should describe the extent of the ERCP as well as the findings. If a biopsy, brushing or washing is done, pathology results are required for a final diagnosis. If a stent was placed, the physician should clearly document the reason for the stent.

Signs and symptoms related to ERCP Procedure

Chronic Pancreatitis
Biliary stricture
Biliary calculus

Reimbursement issue Related to ERCP Procedure

The APC assignment for all ERCP codes is 0151. Many ERCP procedures may require that a sphincterotomy/papillotomy be performed in order to allow access to perform the second surgery (eg, removal of calculus). Review the operative note carefully to
determine if both procedures were performed and assign code 43262 as a secondary code. The sphincterotomy will be reimbursed at a reduced rate. Do not report 43262 in conjunction with 43274, cannulation of papilla, for stent placement or replacement in the same location.
Multiple ERCP procedures are often performed in the same operative session and would be reimbursed at 100% for the first procedure, the second and subsequent procedures will be reimbursed at a reduced rate. For Medicare OPPS, radiological supervision and interpretation codes 74328, 74329, and 74330 are assigned a payment status of
“N” and reimbursement for these services is considered packaged into the APC for the ERCP procedure.

Issues related to Coding ERCP Procedure

When coding ERCPs, as with any procedure, be sure to completely read the procedure report. It is important to understand the extent of the endoscopic procedures, as this will affect the final code assignment(s). For example, a diagnostic ERCP may have been the planned procedure, however due to unforeseen circumstances the scope could only be advanced into the proximal duodenum. In this case, only an esophagogastroduodenoscopy (EGD) should be coded (43235).

The 59 modifier is not required on ERCP codes unless multiple stents are inserted in different areas of the biliary tree or if both biliary and pancreatic  sphincterotomy/papillotomies were performed, code 43262. When reporting an additional separate stent placement (43274), dual biliary andpancreatic sphincterotomies (43262) or an additional separate stent removal and/or replacement (43276), a modifier 59 is required. One or more codes from range 43261 through 43278 may be assigned together. For example if a suspicious area was biopsied during an ERCP and a polyp was removed from another area during the ERCP both the biopsy, 43261, and the polypectomy, 43278, would be assigned.
Add-on code 43273, Endoscopic cannulation of papilla with direct visualization of common bile duct(s) and/or pancreatic duct(s), is to be used in addition to one of the following primary procedure codes, 43260-43278.

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