The biliary tract plays a critical role in the digestive process by transporting bile from the liver to the gallbladder and then to the duodenum. However, when bile ducts become obstructed due to conditions like tumors, scarring, inflammation, or gallstones, patients can experience severe symptoms such as jaundice, abdominal pain, and nausea. To address these blockages, both open surgical and minimally invasive percutaneous procedures are utilized. These and other circumstances prove challenging to coders. Even more, Medicare revisions have altered the global periods for many of these procedures, impacting how they are coded and reimbursed. This month, we explore the nuances of biliary tract coding, providing crucial insights for ensuring accurate and compliant CPT® coding, which is vital as healthcare providers navigate the challenges of payment cuts and strive to maximize reimbursement.
First, let’s understand some of the basics to enhance comprehension of the total service. Bile is a fluid that is created in the liver, then flows through bile ducts (tubes/passages) into the gallbladder where it is stored. When a person eats, bile flows from the gallbladder through the bile ducts into the duodenum where it helps with digestion by breaking down fats into fatty acids. When a bile duct becomes blocked, bile cannot flow into the duodenum causing jaundice, abdominal pain, fever, nausea, vomiting and other symptoms. Some of the causes of blockages are tumors, scarring, inflammation, and gallstones.
Open surgical procedures are available for evaluating and treating bile-duct blockages. However, minimally invasive percutaneous procedures performed by interventional radiologists are increasingly common. Medicare has updated the global periods for most of these procedures from 90 days to 0 days. Diagnostic exams, imaging, and supervision and interpretation are now included in most therapeutic procedures when performed in the same session.
A patient with cholecystitis (inflammation of the gallbladder) may need to have a drainage catheter placed. When a physician places the drainage tube through the abdominal wall into the gallbladder, code 47490—a complete code—is assigned. Note that this code continues to have a 10-day global period.
| 47490 | Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation |
Note there are some significant nuances in this area. Injection of contrast to evaluate a previously placed cholecystostomy tube should be reported with cholangiogram through existing access code 47531. Cholecystostomy check and change would be reported with code 47536—exchange of biliary drainage catheter. Understand that this code would be inclusive of contrast injection through the existing catheter.
However, no additional imaging or guidance codes should be assigned. Imaging of the bile ducts after injecting contrast is known as a cholangiogram. Depending on the specific circumstances, several codes are available for use.
| 74300 | Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation |
| +74301 | Cholangiography and/or pancreatography; additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure) |
When a radiologist interprets images from a cholangiogram being performed in surgery, he would code 74300-26-52 for the initial set of images. If a subsequent set of images is returned for interpretation, assign code 74301-26-52. Modifier 26 is added to these codes to indicate that only the professional component is being billed. Modifier 52 indicates that a lesser service is performed, in this case interpretation only, not supervision.
| 47531 | Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; existing access |
| 47532 | Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; new access (e.g., percutaneous transhepatic cholangiogram) |
It is important to note that the two codes above for stand-alone percutaneous diagnostic cholangiography replace codes 47500, 47505, 74320, and 74305. Both codes are complete codes, and account for the injection of contrast, imaging, and supervision and interpretation.
Code 47531 is reported when a diagnostic cholangiogram is performed through an existing access such as a T-tube or external biliary drainage catheter.
When there is no existing access to the biliary system, code 47532 is reported for the percutaneous access and diagnostic cholangiogram. This may be referred to as a “PTC” or a “PTHC” (percutaneous transhepatic cholangiogram). Do not report 47531 or 47532 with 47533–47541 as diagnostic cholangiography is included in these therapeutic procedure codes.
| 74328 | Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation |
| 74329 | Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation |
| 74330 | Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation |
Understand that surgeons also may evaluate the biliary and pancreatic system endoscopically. Codes 74328, 74329, and 74330 are assigned when a radiologist supervises and interprets fluoroscopic images taken during endoscopic retrograde cholangiopancreatography (ERCP) (43260–43278). If the radiologist does not supervise the imaging (in the room) when the ERCP is done, but later interprets the resultant films, they would add modifiers 26 and 52 to the S & I code.
Code 74328 is assigned when imaging of only the biliary ductal system is documented. This includes the common bile duct, right hepatic duct, left hepatic duct, and cystic duct/gallbladder.
Report 74329 if imaging of the pancreatic ductal system is performed and documented. Both major and minor pancreatic ducts are included in 74329. If both the biliary and pancreatic ductal systems are imaged and interpreted, assign code 74330.
These are NOT all the tips and tricks necessary to tackle GI/Biliarycoding.
As service volumes rebound and every dollar of reimbursement counts more than ever in the face of payment cuts, it’s imperative to make sure your CPT® coding is correct and compliant. Master more IR coding topics and break down the complexity with our expert-infused 2024 2024 GI/Biliary Interventional Radiology Codinglive on June 12, 2024, at 11:00 am, or on demand past this date. This webcast is an essential training tool for both audio and visual learners.
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