# lap assisted PEG tube placement



## lindacoder (Jun 19, 2013)

Abdomen was prepped and draped in the normal sterile fashion. Local anesthesia was infiltrated to the right lower abdomen and an incision was made to accomodate a 5 mm port. Under countertraction an optical viewing trocar was placed. Pneumoperitoneum was then established to 14 mmHg. The abdomen was inspected and there was found to be no trocar related injury. At this point, the endoscope was advanced with mild difficulty through the oropharynx. This was however done under direct visualization. The scope was then advanced into the stomach. The stomach wsa then insufflated. Under direct visualization the canulating needle was then palced transabdominally and into the lumen of the stomach. The guidewire was advanced and this was grasped with the snare via the endoscope. The endoscope and wire were then removed from the mough. A 20-French gastrostomy tube was then advanced over the wire. A small incision was then made over the wire site on the anterior abdominal wall. The gastrostomy tube was then pulled though and was found to sit at 4 cm at the skin. The appropriate adapters were then applied. The gastroscope was not readvanced into the stomach as it is difficult to traverse the oropharyynx initially. The stomach was then allowed to decompress through via gastrostomy tube. The gastrostomy tube hub what then secured to the skin with nylon. The right lower quadrant incision site was then closed with a 4-0 Monocryl.


I am looking at 43246 with maybe modifier 22. THe patient has Railroad Medicare.  Any input would be much appreciated.

Thanks


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## Kisalyn (Jul 1, 2013)

I am not familiar with lap assisted peg tube placement. All of our physicians perform these with endoscopic assistance. My experience with modifier 22 is that the documentation needs to be clear that it took a significantly more amount of effort, time, and/or was technically difficult.

Hopefully, someone else can chime in.


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