ED Coding and Reimbursement Alert

Question: The ED physician treats a patient with a malfunctioning gastrostomy tube (G tube). The patient's physician inserted the tube three weeks ago, and notes indicate that it just "popped out of place." After an exam, the physician removes the old tube and installs a new one; during the placement, he uses fluoroscopic guidance to ensure proper tube placement. How many codes can I report for this encounter? Is this all an E/M service?

Massachusetts Subscriber

Answer: You can code for the E/M and the G tube placement. On the claim, report the following:

• 49450 (Replacement of gastrostomy or cecostomy [or other colonic] tube, percutaneous, under fluoroscopic guidance including contrast injection[s]; image documentation and report]) for the replacement

• modifier 26 (Professional component) appended to 49450 to show that you are coding only for your physician's role in the monitoring

• the appropriate-level code, such as 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...), for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code to show that the E/M and G tube replacement were separate services

• 536.42 (Mechanical complication of gastrostomy) appended to 49450 and the E/M code to represent the malfunction.