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Use of Fluroscopy codes during ERCP

Sandeep Posted Tue 17th of July, 2018 11:31:55 AM
All the CPT codes mentioned in ERCP series do not instruct to use fluroscopy codes which is usually mentioned in parentheses below the code. Page no 295 of CPT manual mentions to use 74328, 74329, 74330 if imaging is performed and saved as permanent record. Our client has performed fluroscopy as mentioned in the medical record during an ERCP procedure. However, NCCI policy manual 2018 for radiology mentions on page no 7 point no 5 as follows" Fluoroscopy is inherent in many radiological supervision and interpretation procedures. Unless specifically noted, fluroscopy necessary to complete a radiologic procedure and obtain the necessary permanent radiographic record is included in the radiologic procedure and shall not be reported seperately. Considering this guideline should fluroscopy be reported with ERCP codes? If fluroscopy is performed by a radiologist and not the gastroenterologist, should we report the service under the gastroenterolgist.?
SuperCoder Answered Wed 18th of July, 2018 07:45:48 AM

Hi Sandeep,

Billing for Fluoroscopy During ERCP

Fluoroscopy is used the most during ERCPs. However, a radiologist will most likely bill for the fluoroscopic imaging during an ERCP and not a gastroenterologist. The majority of the time, there will be a radiologist present and he or she will be billing for the S&I, says Peter Pardoll, MD, a gastroenterologist in St. Petersburg, Fla., and the former co-chair of the National Gastrointestinal Carriers Advisory Committee.

Sometimes I cant get a radiologist to come down to the procedure room, so then I handle the radiological S&I with the assistance of a radiology technician, and I bill for the fluoroscopy. If you do the work, you should be the one to get paid for it.

In the rare case where a gastroenterologist performs the fluoroscopic supervision and guidance during an ERCP, CPT 2001 tells coders to use one of the following three radiological codes depending on whether the biliary, pancreatic or both ductal systems were visualized:

74328 endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation

74329 endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation

74330 combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation

Attach Modifier -26 to Radiological Code

Finally, many gastroenterologists question whether modifier -26 needs to be added to the radiological code. Certain medical procedures are made up of a physician (professional) component and a technical component, which represents the value assigned to the ownership and maintenance of the equipment. (Though CPT guidelines do not specifically address billing for the technical component of a procedure, Medicare and some commercial insurers have designated the modifier -TC to represent this.)

When a procedure has both professional and technical components, a gastroenterologist must own (or partially own by being a partner in a medical practice) the equipment being used to bill the global procedure code. If the physician does not own the equipment being used, modifier -26 should be added to the procedure code.

Some gastroenterologists argue that the use of the phrase radiological supervision and interpretation in all the fluoroscopy codes indicates that these codes are not made up of two components, but only the one professional component. Therefore, modifier -26 should not be added to any fluoroscopy code, and the physician should receive the higher reimbursement of the global code.

In fact, all of the ERCP codes (43260-43272) now include fluoroscopy, regardless of time or resources used. The edit means you can never report an ERCP and a fluoroscopy separately with either:

•76000 - Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) or

•76001 - Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]).

Exception: If your physician is the official reader of the x-ray cholangiogram, you can add the claim for interpretation of the radiology study with modifier -26 (Professional component) appended.

Please feel free to ask for any further quiery. Thank you.

Sandeep Posted Wed 18th of July, 2018 08:52:23 AM
Page no 295 of CPT manual mentions to use 74328, 74329, 74330 if imaging of ductal systems is performed and saved as permanent record. As this guideline is given in CPT manual, in which circumstances we should use above mentioned codes and which conditions we should use 76000 or 76001. If all ERCP codes now include fluoroscopy, with which reference is the above guideline mentioned on page no 295 of CPT manual? Please advise.
SuperCoder Answered Thu 19th of July, 2018 08:46:53 AM

Hi Sandeep,

We will never use 76000 or 76001 with ERCP codes, as per CCI guidelines these two codes are component of 43260-43272. However, ERCP With Radiologic Supervision and Interpretation (S&I) for 74328, 74329 and 74330 exist.  

Before you bill radiologic supervision and interpretation, make sure to double check these items:

The gastroenterologist must indicate in his notes that he supervised the ERCP, and he must also complete a separate note for his radiologic interpretation of the procedure x-ray images.

The service is reportable only one time. In hospital settings, the radiologist may report 74328-74330 ahead of the gastroenterologist. In this case, the physician is barred from reporting the codes even if she prepares a separate report.

You should append modifier 26 (Professional component) to 74328-74330, as appropriate, if the gastroenterologist provides the service in a facility setting. Hope it helps.

Sandeep Posted Fri 03rd of August, 2018 04:16:32 AM
If a gastroenterologist performs S & I of fluroscopy service during ERCP in the absence of a radiologist in hospital setting, can the gastroenterologist report the S & I with 26 modifier? Please provide reference for this scenario.
SuperCoder Answered Tue 07th of August, 2018 05:01:18 AM

As per CMS guidelines,  gastroenterologist can report the S & I with modifier 26 in absence of radiologist.

Since service is reportable only one time, >If the radiologist is not present for the fluoroscopy procedure and your gastroenterologist is the person who is doing the supervision and producing an official interpretation report, then you can bill the S&I in your gastroenterologist's name.

>Be sure that a radiologist is not also interpreting the images at a different time with a separate report and submitting the same codes in a claim of his own. Even though the code contains the phrase "radiological supervision and interpretation," you still have to append the modifier 26 (>Professional component>) to the code unless your gastroenterologist also owns the fluoroscopy equipment that is being used for the procedure. 

>You may follow the below given links for further clarity. Thank you.

>https://www.supercoder.com/coding-newsletters/my-gastroenterology-coding-alert/you-be-the-coder-capture-fluoroscopy-separate-from-ercp-when-appropriate-124714-article

>https://www.supercoder.com/coding-newsletters/my-gastroenterology-coding-alert/endoscopic-retrograde-cholangiopancreatography-43262-43269-is-your-guide-to-profitable-ercp-coding-article

 

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