tci General Surgery Coding Alert - 2014 Issue 1

Reader Question: Code Service Beyond ERCP

Question: How should we report an ERCP when the surgeon extracts a gallstone and performs a sphincterotomy? During the same operative session the surgeon also biopsies an ulcer in the stomach. SuperCoder Subscriber Answer: You can report multiple codes for the distinct services that this surgical case encompasses. For the endoscopic retrograde cholangiopancreatography (ERCP) with removal of a gallstone, you should report 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts). You can additionally report the sphincterotomy using 43262 (…with sphincterotomy/papillotomy). In fact, a new text note following 43262 in CPT®...

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