ED Coding and Reimbursement Alert

Patients who report to the ED with displaced or malfunctioning gastrostomy tubes (G tubes) present an immediate challenge for physicians and coders.

Physicians need to work quickly to replace these tubes, because the patient could be missing enteric nutrition, liquid or medication that the G tube provides.

Coders need to make sure they find every reportable service for these claims, or the practice will miss out on deserved reimbursement. Check out this advice on filing the most complete G tube replacement claims.

If a patient reports to the ED for a G tube replacement, the physician will almost certainly have to perform a separate evaluation and management service to make sure the patient does not have other complications.

"If the ED provider is not the patient's private MD, she is not familiar with the patient, nor does she know why the tube needs to be replaced," says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers. "This could warrant a separate E/M -- but of course, the circumstances could vary," she says.

"Most well-documented G tube replacement encounters would involve an evaluation of the patient's hydration status and a review of their medications to see if any had been missed. As such, an E/M would apply," says Eli Berg, MD, FACEP, chief operating officer of Medical Reimbursement Systems Inc., an ED billing company in Woburn, Mass., and chair of National ACEP's Reimbursement Committee.

Example: A patient with a malfunctioning G tube reports to the ED; she is a patient in a nursing home, and appears dehydrated upon evaluation by the physician. The physician checks baseline laboratory studies and rehydrates the patient with an IV of normal saline for an hour. The physician then checks the patient's other systems and reviews her medication regimen. Notes indicate a level-four E/M service.

The physician then discovers a mechanical glitch in the patient's G tube, which she replaces.

On the claim, you would report the following codes:

- 43760 (Change of gastrostomy tube) for the tube replacement.

- 536.42 (Mechanical complication of gastrostomy) attached to 43760 to represent the tube malfunction.

- 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity) for the E/M service.

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to 99284 to show the insurer that the E/M was a separate service from the G tube replacement.

- 276.51 (Dehydration) linked to 43760 and 99284 to represent the patient's dehydration.

Depending on your practice's coding polices, you might also consider reporting 90760 (Intravenous infusion, hydration; initial, up to one hour) to represent the hydration service if properly documented.

In addition to the possibility of an E/M service, coders should also check to see if the physician used either radiologic guidance or contrast monitoring during the G tube replacement.

Why? Because you can report these services separately, Pfaff says.

Who needs it? "Monitoring is usually done in a relatively fresh G tube (4-6 weeks old) where the physician wants to confirm that it is in the gastrointestinal tract, or if the physician encounters some difficulty in placing the tube," Berg says.

At times, it may become technically more difficult to replace the tube if there is not an established tract. "An established tract is usually present after the G tube has been in place for roughly four weeks," Berg says.

Also, If the G tube is relatively fresh or if the patient presents a technical challenge (possibly due to obesity), the physician will instill some contrast material to ensure that the tube is placed properly before tube feeds are restarted, he says.

Suppose the ED physician uses radiologic guidance to replace a G tube. On the claim, you would report 43760 for the replacement.

Also, report 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation) with modifier 26 (Professional component) attached to show that you are only coding for the professional portion of the guidance, Pfaff says.

It is true that G tube replacements are more common in the ED than other tube procedures; however, your physician may also be called on to service suprapubic cystostomy tubes.

When your physician replaces one of these tubes, report one of the following:
- - 51705 -- Change of cystostomy tube; simple
- - 51710 -- ... complicated.