Gastroenterology Coding Alert

Aggressive Coding Practices for ERCP Stent Placements Aim for Higher Payments

- Published on Sat, Sep 01, 2001
To claim better reimbursement, many gastroenterology practices are changing how they report some ERCP stent procedures. For stent replacements and multiple stent placements, gastroenterologists will have to determine how aggressive they want to be when billing because there are no definitive guidelines from CMS or local carriers on how these procedures should be coded. 
Stents can be placed during an ERCP in both the bile and pancreatic ducts. They are used to keep the ducts open and bile flowing when an obstruction, often due to cancer, threatens to close the duct, according to Sarkis J. Chobanian, MD, FACP, FACG, a gastroenterologist in Knoxville, Tenn. The stents are made of several materials. Plastic stents are usually placed temporarily, while metal mesh stents are for long-term placements. But neither the duration of the placement nor the material the stent is made of affects how a stent procedure is coded.
Three Methods for Billing Removal/Replacement  
When the stents have to be removed and replaced because they have become occluded, there are at least three different ways to report the procedure. Coding is confusing because most gastroenterologists consider the replacement of an ERCP stent to be two procedures: the removal of the old stent (43269) and the insertion of the new stent (43268). Many gastroenterology practices have traditionally avoided reporting both codes together, because they are listed as a mutually exclusive edit in the Correct Coding Initiative (CCI). Mutually exclusive codes are those procedures that cannot reasonably be done in the same session.
"We would never bill for both the removal and replacement of a stent in the same session," says Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 23-physician practice. "It's a mutually exclusive coding combination, and we don't think we would ever get paid for it. Our physicians feel that there isn't any more work involved in doing a removal and replacement because the bile or pancreatic duct is still open."
The most conservative approach to billing a stent removal and replacement is to report only 43269, which pays $381 on an unadjusted basis when performed in a facility. Because the CPT description of this code includes the phrase "removal of foreign body and/or change of tube or stent," many gastroenterology practices feel that this code comes closest to describing the entire procedure.
In addition, Medicare payment rules direct carriers to reimburse the lesser-valued code, which in this situation is 43269, when two mutually exclusive edits are reported on the same claim. Some gastroenterology practices interpret this to mean that they must only report the lesser-valued code when it [...]

Get 14-Day Fully-Functional Free Trial of Physician Coder

Get access to all your specialty alerts and archived articles along with some comprehensive tools including:
  • Code Search for CPT®, HCPCS, ICD-9 and ICD-10
  • CCI Edits Checker
  • Part B Fees, MUEs
  • CPT-ICD-9 CrossRef
  • CPT® ↔ ICD-9 ↔ ICD-10 CM Crosswalk
  • LCD/NCD Lookup
  • CMS 1500 Claims Scrubber
  • NDC ↔ CPT/HCPCS CrossReference
First Name: *
Last Name: *
User Name: *
E-mail: *
Phone: *
Choose Speciality*
Please enter the characters shown in box*