Effective Date: June 25, 2021

Purpose:

This policy provides guidelines on reimbursement when performing an endoscopic retrograde cholangiopancreatography (ERCP) with removing or exchanging a stent, removing a foreign body or performing a Sphincterotomy, in addition to removal of calculus or debris.

Scope:

Products included:

• NJ FamilyCare/Medicaid
• MLTSS

Definitions:

• Endoscopic retrograde cholangiopancreatography (ERCP): A diagnostic procedure that combines upper endoscopy and retrograde or reverse, injection of contrast material, a type of dye, into the biliary ducts to obtain fluoroscopic images of the gallbladder, pancreas, and bile ducts.
• CPT code 43264: Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s).
• CPT code 43274: Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent.
• CPT code 43275: Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s).
• CPT code 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 performed, including sphincterotomy, when performed, each stent exchanged.

Policy:

Horizon NJ Health will deny CPT code 43264 (Endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic duct[s]) when billed with CPT code(s) 43274-43276 (Endoscopic retrograde cholangiopancreatography [ERCP] with placement of stent; removal of stent or foreign body; stent exchange; balloon dilation).

Modifier -59 can be appended to CPT code 43264 if this service is consider separate and unique from the ERCP service.

Procedure:

Horizon NJ Health shall not consider for reimbursement CPT code 43264 without a Modifier -59 when billed with CPT code(s) 43274-43276.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association.  In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

•  Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services.