I need help with coding this ERCP.
Would you only bill 43275 since the balloon sweep was clear??
What is the appropriate dx code to use for removal of stent?
With the patient in the prone position, the Olympus side-viewing duodenoscope was introduced into the oropharynx and advanced under direct vision towards the esophagus, stomach, and descending duodenum. Screening views of the esophagus and stomach were normal. A biliary stent was visualized protruding from the major papilla. The stent was grasped with a snare and subsequently removed without difficulty.
The biliary tree was cannulated using a balloon catheter. A cholangiogram was then performed. The right and left intrahepatic biliary tree was normal. The common hepatic duct was normal. The common bile duct was normal. No filling defects were visualized within the biliary tree. The balloon was then inflated at a 8.5 mm at the level of the common hepatic duct. No stones were noted to exit the papilla after several balloon sweeps. The contrast was aspirated from the biliary tree. The scope was subsequently removed.
1) Removal of biliary stent
2) Normal cholangiogram without evidence of filling defects
I just recently took over coding/billing for ERCP’s, so I'm still learning.
The diagnosis depends on the reason for the procedure, there is not a specific diagnosis that should be billed with this procedure. You would report your findings or the reason for the encounter.
Notice below in the description the removal of the stent is included in this procedure;
43275 - Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s).