QUESTION 6 - A 24-year-old patient with sphincter of Oddi dysfunction presents for removal of a biliary stent via an EGD. A videoendoscope is inserted into the oral cavity and multiple biopsies were taken from the proximal stomach. The biliary stent was located in the second portion of the duodenum in the ampulla, where it was removed by snare device. How should this procedure be reported?
ANSWER - Report CPT code 43239, Upper
gastrointestinal endoscopy including esophagus, stomach, and either the duodenum
and/or jejunum as appropriate; with biopsy, single or multiple, for the EGD with
biopsies of the stomach.
According to the CPT codebook, in the index under Removal, stent, bile duct or pancreatic duct, the coder is guided to CPT code 43269, Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of foreign body and/or change of tube or stent.
Therefore, when supported by physician documentation CPT code 43269 would be reported for the removal of a biliary or pancreatic stent if an ERCP is performed. If an ERCP is not performed CPT code 43247, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and /or jejunum as appropriate, with removal of foreign body, would be reported for the removal of the biliary or pancreatic stent. Otherwise query the physician for clarification when the documentation is unclear.
Article Number: 28
Posted: Tue, Nov 16, 2010 8:47 PM
Last Updated: Tue, Nov 16, 2010 8:47 PM
Online URL: http://qhr.knowledgebase.co/article/removal-of-biliary-stent-via-gastroscopy.html