ED Coding and Reimbursement Alert

You need a different code for radiologic supervision

If a patient's gastrostomy tube (G tube) suddenly malfunctions, he will likely be unable to get the liquids, nutrients or medications that he needs, creating an emergency. For this reason, many patients with malfunctioning G tubes end up in the ED for treatment.
 
Who needs them? -G tubes are necessary for patients who need enteric nutrition, or any patient unable to have any oral intake for a prolonged period of time,- says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers.
 
Physicians may also administer medications through G tubes, says Elijah Berg, MD, FACEP, chief operating officer of Medical Reimbursement Systems Inc., an ED billing company in Stoneham, Mass.

Don't Let Problems Clog Reimbursement

According to Pfaff, when the liquid (IV fluid, medication, enteric nutrition, etc.) passes through the G tube, it can clog, kink, dislodge or malposition the tube, creating the need for a replacement.
 
For proper G tube replacement claims, the coder must be ready to check the physician's notes:
 
- for evidence of separate E/M services the ED physician might provide along with the G tube service.
 
- to see if the physician used contrast monitoring during the procedure.

- for evidence of radiologic supervision and interpretation during the procedure.

Only then can a coder choose the right G tube code combination for the claim. Read on for a primer on selecting spot-on codes for your G tube services.

Separate E/M From Tube Procedure

When the encounter occurs in the ED, G tube replacements nearly always involve a separate E/M, Berg says.

-When a patient comes to an ED, it is the physician's legal and ethical obligation to evaluate the patient for the presence or absence of an emergency medical condition,- he says.
 
According to Berg, patients with displaced or non-functioning G tubes should have their hydration status and living situation evaluated. Further, the physician should assess the appropriateness of the patient's current care and check if the patient missed any doses of medications.
 
-There is no cookbook answer as to what (E/M) level this could be,- Berg says. -But if concern warrants labs to be drawn, or there is coordination of care with another physician, the service might warrant assignment of 99284.-
 
For example: A patient with a displaced G tube and evidence of dehydration comes to the ED from a nursing home. The emergency physician performs a detailed history and physical exam and orders labs, as well as IV fluids for rehydration. Examination of the tube shows a significant clog.
 
The physician reviews the lab tests, rehydrates the patient and changes the G tube before discharging him  back to the nursing home.
 
On the claim, you should:

- report 43760 (Change of gastrostomy tube) for the tube replacement.
 
- report 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.
 
- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99284 to show the insurer that the E/M was a separate service from the G tube replacement.

An E/M Assumption Could Hurt Your Claim

Don't assume anything on a G tube replacement claim, and be sure to double-check the notes when deciding the E/M level for all of your G tube replacement patients. First, find out if the physician performed a separate E/M service. If she did, decide on the service level based on the notes she provides.

Don't Forget Radiologic Supervision

You should also use 43760 if the physician puts the same G tube back into place. So if a patient presents to the ED with a G tube that has fallen out and the physician re-inserts, you can still report 43760. -Any re-insertion (either of the existing G tube or of a brand-new tube) warrants coding of 43760,- Berg says.
 
So in most instances, you will be reporting 43760 when a patient reports to the ED for G tube replacement.

There is, however, an exception to this rule:
 
If the ED physician needs contrast monitoring or radiologic supervision and interpretation to change a G tube, report 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation) appended with modifier 26 (Professional component), Berg says.
 
ED coders use 75984 when the physician needs radiologic confirmation of the tube placement due to technical difficulties associated with the patient's anatomy or the placement of the tube itself, Berg says.

ED Physician Might Also Replace Cystostomy Tube

While you will be coding for G tube replacements more often than any other tube procedure in the ED, your physician may also replace suprapubic cystostomy tubes, Berg says.
 
Code these tube replacement procedures with one of the following:
 
- 51705 -- Change of cystostomy tube; simple
 
- 51710 -- ... complicated.

For simple suprapubic cystostomy tube replacements, use 51705. But if the notes indicate a complicated tube change, report 51710. 
 
For example, if the physician must dilate the tract before inserting the tube, or pass a wire and pass the catheter over the guidewire, use 51710.