# How to code this g-tube/gj-tube??



## suela923@aol.com (Apr 25, 2014)

Hello!  Can anyone help me code this?  I thought it was 49440,49446.  Also would the statement "image guided" be enough for documentation or must he actually state "fluoroscopy"?
Thanks,
Sue 


  GASTROSTOMY TUBE PLACEMENT

GASTROJEJUNOSTOMY TUBE PLACEMENT

History:

Duodenal ulcer with perforation status post repair. Requirement of jejunal feeding as well as gastric decompression.

Technique:

Risks and benefits of the procedure were discussed with the patient's family/partner and informed consent was obtained. The patient was placed supine on the fluoroscopic table, and the upper abdomen was prepped and draped in the usual sterile fashion; 2% lidocaine was administered for local anesthesia. General anesthesia was monitored by the department of anesthesia.

The left upper quadrant was evaluated with ultrasound with acquisition of permanent images. A scout radiograph was then obtained with a hemostat positioned below the inferior aspect of the left liver edge. The existing Dobbhoff tube was then used to inflate the stomach with approximately 300 cc of air; 0.5 gm of glucagon was administered intravenously.

A skin incision was made overlying the gastric antrum. An 18-gauge needle was then advanced into the gastric lumen in the region of the gastric antrum via the lateral aspect of the skin incision. Air was aspirated, and contrast was injected to confirm locationing. A Cope anchor was then advanced into the stomach and secured to the skin. This process was repeated at the medial aspect of the skin incision, and a 0.035 inch Amplatz superstiff wire was left coiled in the stomach via the Cope needle. An 18-gauge single wall needle was then used to access the stomach in an antegrade fashion via the central portion of the incision. An Amplatz wire was coiled in the stomach, and a combination of wires and catheters was used to manipulate into the jejunum. Following serial fascial dilation, a 14-French Shetty gastrojejunostomy tube was advanced into the small bowel. The proximal locking loop was secured, and contrast was injected to confirm positioning. A 12-French locking loop drainage catheter was then placed over the remaining Amplatz wire within the stomach. Contrast was again injected via this catheter to confirm location. Both catheters were secured to the skin, and a sterile dressing was placed, terminating the procedure. The patient was transferred to the PACU in satisfactory condition.

Findings:

Limited grayscale ultrasound images of the left upper quadrant reveal no evidence of liver in the subcostal region. Scout radiograph at the inferior costal margin reveals no overlying colon. Following inflation of the stomach, there was successful placement of 2 Cope suture anchors as described above. There was then successful placement of a 14-French Shetty gastrojejunostomy tube. Contrast injection confirmed placement of the tip within the proximal jejunum. The proximal locking loop was secured within the stomach. There was also successful placement of a 12-French locking loop gastrostomy tube within the stomach. Contrast injection confirmed positioning within the gastric fundus.


Result Impression 


1. Successful image-guided placement of a 14-French Shetty gastrojejunostomy tube with the tip positioned in the proximal jejunum.

2. Successful image-guided placement of a 12-French decompressive gastric tube.


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## jkayser (Apr 28, 2014)

Hello, the fluoroscopy is included in both 49440 & 49446 and would not be separately billable.  Both the gastrostomy tube and the GJ tube were placed through the same incision.  There does not appear to have been any extraordinary difficulty in placing the tubes.  If the placement of 2 separate tubes significantly increased the length of the procedure, it would need to be documented to justify a 22 modifier.  Here is a link regarding the appropriate use of this modifier: 

http://news.aapc.com/index.php/2011/06/append-22-to-unusually-difficult-procedures/ 

The physician documented an ultrasound with permanent images of the left upper quadrant and noted the findings.  CPT 76705 is for a limited ultrasound and is appropriate for examination of a single quadrant.  Add modifier 26 if needed according to the place of service.  

The physician also documented a "scout view" and the findings.  CPT 74000 would be appropriate for this x-ray.  Add modifier 26 if needed according to the place of service.  Here is a link that explains a scout view:  http://news.aapc.com/index.php/2010/09/seven-tips-for-diagnostic-radiology-coding-success/

I hope this information is helpful.  

Jean Kayser CPC CIRCC


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