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Question: ERCP-Stone crushing

Vickie Posted Wed 28th of September, 2011 12:47:39 PM

Could someone please help me with the following: Physician did an ERCP. The main bile duct contained two stones. Note Says: Stent removed with snare. No bile leak anymore. One large grabbed with basket. Could'nt pull it out. Therefore, stone crushed with basket into multiple fragments. All the fragments removed with balloon sweeps. Could someone help please? Would this be 43269 & 43264?

Thanks,

Vickie

SuperCoder Answered Wed 28th of September, 2011 15:37:16 PM

43264
43269-51

Carol Answered Thu 29th of September, 2011 14:15:37 PM

I was wondering why you chose NOT to code for a lithotripsy, 43265 - The note does not say lithotripsy, however, stones were crushed and I feel this code could could be used. Also, was there a reason for your choice of modifier 51 in lieu of a 59 modifier. These procedures are of the same family but separate and distinct.

SuperCoder Answered Thu 29th of September, 2011 15:17:30 PM

I agree with you in choosing the CPT 43265 for I missed the lithotripsy one. But, regarding modifier 51 or 59, I request your feedback on following analysis:
43265 and 43269 has base endoscopic code 43260. Beloging to the same family of codes doesn't change the modifier, but change the reimbursement calculation techniques.
When 43265 and 43269 are billed togegher, it has to be billed 43265 first with reimbursement at its full value of the procedure and then 43269-51 where the payement will be the difference between the value of the 43269 and the base endoscopic code 43260.

Vickie Posted Sat 01st of October, 2011 16:04:09 PM

Carol,
Are you saying use both the 43264 & 43265?

Thanks

Vickie Terry

SuperCoder Answered Mon 03rd of October, 2011 02:18:09 AM

Ok, from my side I can submit the proof which tells how to bill codes of same family. Rest is up to you.

Carol Answered Mon 03rd of October, 2011 19:56:49 PM

Yes, I am saying to use all three codes, 43264-59, 43265, and 43269-59. These codes are all separate and distinct and are not bundled together.

Nikhil Answered Mon 03rd of October, 2011 22:09:14 PM

A very old link, but enough to clarify the concept:
http://www.supercoder.com/articles/articles-alerts/gac/optimize-reimbursement-for-ercps/?zoom_highlight=43265+and+43269
Check the details in the title "Code for an ERCP Instead of an EGD" for correct understanding of coding on the concept of "endoscopic base code".

Carol Answered Wed 05th of October, 2011 21:29:19 PM

Thanks - old but helpful!

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