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Is 43231 included in ERCP?

Maarit Posted Thu 05th of January, 2012 17:26:18 PM

Side viewing duodenoscope was passed through the mouth into the duodenum. Attempt to cannulate the common bile duct failed after multiple attempts.
Dr wants to bill for 43260 and 43231. is this correct? Also, should I use mod. 53 since the attempt was failed?
thank you for your help.

SuperCoder Answered Thu 05th of January, 2012 20:38:45 PM

Procedure 43231 is not included in 43260. But, here the documentation doesn't support 43231. For 43231, there should be documentation of replacement of esophagoscope with echoendoscope or ultrasound probe which is not mentioned in the question.
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Since ERCP is not complete in any way, so we can't code 43260. I can't find any justification for billing both 43260 and 43231. At the same time, modifier 53 is only used for discontinued procedure due to mitigating circumstances or those threatening the life of the patient and procedure was discontinued. I would like to go for modifier 52 as the surgeon does not complete procedure 43260 in its entirety.
The reimbursement will be based on what was completed and accomplished. A code (43235) will be assigned to indicate the portion of the procedure that was completed. The operative report must be attached for determination reimbursement.

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