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Outpatient Facility Coding Alert

You Be the Coder:

Here's When You Can Correctly Report 43277 In Addition to 43264

Question: During an ERCP procedure, the surgeon removed three stones. How should we code this case?

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Answer: Given the information you've provided about the procedure, the best code choice is 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with removal of calculi/debris from biliary/pancreatic duct[s]).

ERCP is a procedure that utilizes endoscopy and fluoroscopy to visualize, examine, diagnose, and possibly treat stones, tumors, or narrowing in the bile or pancreatic ducts. Two commonly used devices for stone removal are a basket and a balloon. A catheter with a basket is passed over a guide wire into the duct and the basket traps the stone, which is then withdrawn into the duodenum and opened to release the stone. A balloon also can be used to dredge out the stones.

Beware:  The most common mistake made when coding this service is to report multiple codes for multiple stones. The 43264 code definition says, "debris/calculi," so it doesn't matter how many stones your surgeon removed. You will code the procedure once-even if multiple methods are used in the same session for stone removal, or if the same or multiple balloon catheters are used multiple times to clear stones and debris from the ducts.

Catch: Although you can report the use of a balloon to remove stones as 43264, you should not confuse that with the balloon dilation of the ampulla, biliary, or pancreatic ducts, which is a separate procedure described by 43277 (Endoscopic retrograde cholangiopancreatography [ERCP]; with trans-endoscopic balloon dilation of biliary/pancreatic duct[s] or of ampulla [sphincteroplasty], including sphincterotomy, when performed, each duct).

If the surgeon must perform sphincteroplasty or dilation of a ductal stricture before proceeding to remove stones/debris from the duct during the samesession, you can report 43277 in addition to 43264, with an applicable NCCI edit modifier as long as the documentation supports the separateness of the procedures.