# PEG + Trach question



## Walker22 (Mar 8, 2016)

Posting for a friend, because this is outside of my area of expertise.


If Dr. X does a Tracheostomy 31600  and PEG  43246  (see copy of op note below)  Which code do I bill first and put a mod 59, correct? 

31600

43246 – 59

or 

43246

31600 – 59



DESCRIPTION OF PROCEDURE:

After having obtained informed consent, the patient was taken to the operating room, placed on the operative table in the supine position.  After placement of appropriate monitoring lines general anesthesia was induced.  Appropriate timeout was taken.  The neck was extended as well as possible and the neck and upper chest were prepped and draped in a sterile fashion.  A transverse 2-2.5 cm incision was made, carried down in the midline onto the pretracheal fascia.  The cricoid cartilage was identified, second and third tracheal rings were then identified.  The tracheal hook was placed just below the cricoid to elevate the trachea.  At this point, in coordination with Anesthesia, a cruciate tracheostomy incision was made between the second and third tracheal rings and the stoma was dilated up to fit a #8 Shiley tracheostomy tube.  The endotracheal tube was withdrawn under direct vision just above the tracheostomy site and the #8 Shiley extra-long proximal tracheostomy tube was placed.  The balloon was inflated.  Good ventilation was demonstrated.  The catheter was suctioned.  The tracheostomy tube was sutured into place.  At this point then the patient was intubated orally with the gastroscope, which was passed under direct vision in the proximal esophagus.  No esophageal abnormalities were encountered.  Inspection of the gastric lumen revealed some mild linear gastritis, previous scarring from previous PEG tube.  No other significant abnormalities identified.  At this point, the gastric lumen was insufflated externally.  The previous PEG tube site was demonstrated with good indention into the gastric lumen.  The gastric wall was unable to be transilluminated through due to her significant obesity.  At this point, the abdominal wall was prepped and draped in a sterile fashion.  Local anesthesia, 1% lidocaine was placed and a small incision was made at the previous site.  The 18 gauge needle was then used and passed directly into the gastric lumen over a short distance and extubated in the gastric lumen near the previous PEG tube scar.  At this point then a PTFE guidewire was passed through the needle, grasped with the endoscope and brought out orally.  The Bard 20 French PEG tube was placed over the guidewire and using push-pull method was brought out through the anterior abdominal wall.  The gastroscope was replaced and the PEG tube was noted to be well seated, no bleeding encountered.  The PEG tube was at 6 cm at the skin level.  The PEG tube was secured, dressing was applied.  Patient was then taken to the PACU.


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## CodingKing (Mar 8, 2016)

Id put it on the Trach code due to the NCCI rule about bundling "separate procedure".  Although I don't see either code listed as a column 2 code to one another so i don't think its necessary. Closest CCI edit I can find is 31600 & 43752 (Naso- or oro-gastric tube placement)


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## kalpana (Mar 17, 2016)

31600 -59    pays more primary code
43246 PEG


Note that 31600 is a separate procedures by definition, are usually a component of a more complex service and are not identified separately. When performed alone or with other unrelated procedures/services, they may be reported. If performed alone, list the code; if performed with other procedures/services, list the code and append modifier 59 or an X{EPSU} modifier.


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