Get Answers to FAQs on Billing Multiple ERCP Procedures

January 06, 2012

Physicians, practice managers and coders are often perplexed by the rules governing the reporting of multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures in the same session. The following FAQs are designed to help answer some of the most common coding scenarios.

What order should ERCP codes be billed? Multiple ERCPs should be reported in order beginning with the code that carries the highest reimbursement amount. The first code reported should not have a modifier appended to it, but each subsequent code should be reported with modifier 59, distinct procedural service.

Are any modifiers required when multiple ERCP codes are billed? When multiple ERCP procedures are performed during the same session or on the same day, modifier 59, distinct procedural service, should be appended to each code beyond the first code reported. This identifies that each procedure is separate and distinct from each other procedure reported.

The only exception is when code 43273; Endoscopic cannulation of papilla with direct visualization of common bile duct(s) and/or pancreatic duct(s), is reported. As this is an add-on code, it does not require a modifier.

How is the removal of “sludge” from the biliary tract reported? Removal of “sludge” can be interpreted as removal of calculi. Therefore, code 43264; ERCP; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts, is appropriate.

Is control of bleeding that is the result of the cutting of a sphincterotomy separately billable? Bleeding as a result of creating a sphincterotomy is not separately billable. However, if the procedure causes bleeding and the patient is brought back to the endoscopy suite later in the day, the provider can report 43255; Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method, along with modifier 78 to indicate this service.

Is it possible to bill multiple units of 43268 if multiple stents were placed? Multiple instances of 43268 can be billed if two stents are placed in two different ducts. Modifier 59 should be appended to the second code and appropriate documentation should be provided. If two stents are placed in a single duct, regardless of position, 43268 should be reported once.

The physician performed cholangioscopy in addition to ERCP. Is it possible to report cholangioscopy separately or is it included in the ERCP code? Code 43273 describes cholangioscopy. As it is an add-on code, it must be reported with an appropriate ERCP parent code. No modifier is necessary when reporting 43273 in addition to a parent ERCP procedure. 43273 can only be reported once per session, regardless of whether more than one duct is examined.

Can 43273 (cholangioscopy) be reported with 43262 (ERCP with sphincterotomy)? Yes, code 43262; ERCP with sphincterotomy/papillotomy describes a distinct procedure that is separately reportable when performed in conjunction with code 43273. The parenthetical following code 43273 was revised in 2010 so that code 43262 may be added to the list of codes that identifies separately reportable procedures.

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