2021 Coding & Payment Quick Reference Select Biliary Procedures Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list. We recommend consulting your relevant manuals for appropriate coding options. The following codes are thought to be relevant to Biliary procedures and are referenced throughout this guide. All rates shown are 2021 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments It is important to remember that surgical endoscopy always includes a diagnostic endoscopy (CPT® Code 43260). Therefore, when a diagnostic endoscopy is performed during the same session as a surgical endoscopy, the diagnostic endoscopy code is not separately reported. (CPT Assistant, October 2001) 2021 Medicare National Average Payment RVUs Physician‡,2 Facility3 CPT® Total Total Hospital Code Description Work In-Office In-Facility ASC Code1 Office Facility Outpatient Diagnostic 43260 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or 5.85 NA 9.38 NA $327 $3,081† $1,381 washing, when performed (separate procedure) Therapeutic 43261 Endoscopic retrograde cholangiopancreatography (ERCP); with 6.15 NA 9.84 NA $343 $3,081† $1,381 biopsy, single or multiple 43262 Endoscopic retrograde cholangiopancreatography (ERCP); with 6.50 NA 10.39 NA $363 $3,081† $1,381 sphincterotomy/papillotomy 43263 Endoscopic retrograde cholangiopancreatography (ERCP); with 6.50 NA 10.39 NA $363 $3,081† $1,381 pressure measurement of sphincter of Oddi 43264 Endoscopic retrograde cholangiopancreatography (ERCP); with 6.63 NA 10.59 NA $370 $3,081† $1,381 removal of calculi/debris from biliary/pancreatic duct(s) 43265 Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, 7.93 NA 12.61 NA $440 $5,029† $2,058 lithotripsy) 43277 Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or 6.90 NA 11.01 NA $384 $3,081† $1,381 of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct 43278 Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and 7.92 NA 12.58 NA $439 $3,081† $1,381 post-dilation and guide wire passage, when performed See important notes on the uses and limitations of this information on page 5. Effective: 1JAN2021 Expires: 31DEC2021 CPT copyright 2020 American Medical Association. All rights reserved. MS-DRG Rates Expire: 30SEP2021 CPT is a registered trademark of the American Medical Association. ENDO-47409-AJ 1 2021 Medicare National Average Payment RVUs Physician‡,2 Facility3 CPT® Total Total Hospital Code Description Work In-Office In-Facility ASC Code1 Office Facility Outpatient Stenting 43274 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, 8.48 NA 13.47 NA $470 $5,029† $2,058 including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent 43275 Endoscopic retrograde cholangiopancreatography (ERCP); with 6.86 NA 10.95 NA $382 $3,081† $1,381 removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) 43276 Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when 8.84 NA 14.02 NA $489 $5,029† $2,058 performed, including sphincterotomy, when performed, each stent exchanged Fluoroscopy is often performed in conjunction with ERCP procedures. Possible CPT Codes include: 2021 Medicare National Average Payment RVUs Physician‡,2 Facility3 CPT® Total Total Hospital Code Description Work In-Office In-Facility ASC Code1 Office Facility Outpatient Fluoroscopy 74328-26 Endoscopic catheterization of the biliary ductal system, radiological No No 0.47 NA .82 NA $29 additional additional supervision and interpretation payment*** payment*** 74329-26 Endoscopic catheterization of the pancreatic ductal system, No No 0.47 NA .82 NA $29 additional additional radiological supervision and interpretation payment*** payment*** 74330-26 Combined endoscopic catheterization of the biliary and pancreatic No No 0.56 NA 1.05 NA $37 additional additional ductal systems, radiological supervision and interpretation payment*** payment*** See important notes on the uses and limitations of this information on page 5. Effective: 1JAN2021 Expires: 31DEC2021 CPT copyright 2020 American Medical Association. All rights reserved. MS-DRG Rates Expire: 30SEP2021 CPT is a registered trademark of the American Medical Association. ENDO-47409-AJ 2 Medicare Transitional Pass-Through (TPT) Payment Category Applicable to EXALT™ Model D Single Use Duodenoscope The Centers for Medicare & Medicaid Services (CMS) has approved Boston Scientific’s application for a transitional pass- through (TPT) payment category to describe single-use endoscopes, such as the EXALT™ Model D Single-Use Duodenoscope. Effective July 1, 2020, the new device pass-through code (C1748) may be used to bill for EXALT Model D when used in the treatment of Medicare patients in the hospital outpatient setting. This device specific payment is in addition to the endoscopic retrograde cholangiopancreatography (ERCP) procedure payment and is intended to cover the cost of the device. TRANSITIONAL PASS-THROUGH CODE The following HCPCS code must be reported on the claim for a hospital to be eligible for TPT payment. Status HCPCS Long Descriptor Indicator C1748 H* Endoscope, single-use (i.e., disposable), upper GI, imaging/illumination device (insertable) The CMS guidance on the new device transitional pass-through category is available at: http://www.cms.gov/files/document/r10166cp.pdf (See Section 7 and Tables 8 & 9). *C1748 has a Medicare status indicator of “H” and therefore is not subject to copayment Medicare patients treated in the outpatient setting will not incur any additional costs for the utilization of EXALT Model D during an ERCP procedure. REPORTING FOR PROCEDURE AND DEVICE ON A CLAIM When physicians perform an ERCP procedure on a Medicare patient in the hospital outpatient setting with EXALT Model D, hospitals, if appropriate, may bill: Procedure coding: Appropriate ERCP CPT code(s) plus Device HCPCS code: C1748 Device Revenue Code: EXALT Model D is a single use sterile device and may be reported using revenue code 278 - Medical/surgical supplies and devices; other implants. For additional coding and reimbursement information, contact your local Endoscopy Reimbursement Manager or the Endoscopy Reimbursement Help Desk at [email protected] or (508) 683-4510. Additional C-Code Information For all C-Code information, please reference the C-code Finder: http://www.bostonscientific.com/reimbursement See important notes on the uses and limitations of this information on page 5. Effective: 1JAN2021 Expires: 31DEC2021 CPT copyright 2020 American Medical Association. All rights reserved. MS-DRG Rates Expire: 30SEP2021 CPT is a registered trademark of the American Medical Association. ENDO-47409-AJ 3 Hospital Inpatient Coding – Select Procedures ICD‐10 PCS ICD‐10 PCS Description Code 0F558ZZ Destruction of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0F568ZZ Destruction of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0F578ZZ Destruction of Common Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0F588ZZ Destruction of Cystic Duct, Via Natural or Artificial Opening Endoscopic 0F598ZZ Destruction of Common Bile Duct, Endoscopic 0F5C8ZZ Destruction of Ampulla of Vater, Endoscopic 0F5D8ZZ Destruction of Pancreatic Duct, Endoscopic 0F5F8ZZ Destruction of Accessory Pancreatic Duct, Via Natural or Artificial Opening Endoscopic 0F758DZ Dilation of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F758ZZ Dilation of Right Hepatic Duct , Via Natural or Artificial Opening Endoscopic 0F768DZ Dilation of Left Hepatic Duct with Intraluminal Device, Endoscopic 0F768ZZ Dilation of Left Hepatic Duct, Endoscopic 0F778DZ Dilation of Common Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F778ZZ Dilation of Common Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0F788DZ Dilation of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F788ZZ Dilation of Cystic Duct, Endoscopic 0F798DZ Dilation of Common Bile Duct with Intraluminal Device, Endoscopic 0F798ZZ Dilation of Common Bile Duct, Endoscopic 0F7C8DZ Dilation of Ampulla of Vater with Intraluminal Device, Endoscopic 0F7C8ZZ Dilation of Ampulla of Vater, Endoscopic 0F7D8DZ Dilation of Pancreatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F7D8ZZ Dilation of Pancreatic Duct, Endoscopic 0F7F8DZ Dilation of Accessory Pancreatic Duct with Intraluminal Device, Endoscopic 0F7F8ZZ Dilation of Accessory Pancreatic Duct, Endoscopic 0FB98ZX Excision of Common Bile Duct, Endoscopic, Diagnostic 0FBC8ZX Excision of Ampulla of Vater, Endoscopic, Diagnostic 0FBD8ZX Excision of Pancreatic Duct, Endoscopic, Diagnostic 0FBF8ZX Excision of Accessory Pancreatic Duct, Via