ED Coding and Reimbursement Alert

If you code 43760 for all tube replacements, you're playing with fire.

A patient presents to the ED with a displaced or damaged percutaneous endoscopic gastrostomy (PEG) tube. The ED physician either replaces the tube or removes it entirely. The coder reports PEG tube procedure code for the service.

Simple, right?

Not so fast: You won't always code a PEG tube service with a procedure code. In some instances, you would report the procedure with the appropriate E/M code instead.

Read on for advice on the ins and outs of coding tube insertions and removals.

Opt for E/M On Removals

Patients who have G tubes often receive medication, nutrition, liquid, etc., through the tube, confirms Eli Berg, MD, FACEP, CEO of Logix Health, an ED coding and billing company in Bedford, Mass. So if a PEG tube malfunctions, the patient will often end up as an ED presentation.

You can use 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance) linked with diagnosis code V55.1 (Attention to gastrostomy) if the physician removes the PEG tube and places another one.

So let's say the ED physician replaces a patient's PEG tube because of clogging; you should choose 43760, says Linda Martien, CPC, CPC-H, coding, documentation and compliance specialist for National Healing Corp. in Mexico, Mo.

You should also employ 43760 if the physician puts the same G tube back into place, says Berg. So if a patient presents to the ED with a G tube that has fallen out and the physician puts the tube back into the proper place, it is a 43760 service.

There are some instances; however, in which 43760 is improper coding for PEG tube services:

Exception 1: Suppose your ED physician only removes the PEG tube and performs no other procedure. In this case, you can report an ED E/M code (99281-99285) for the service.

Exception 2: If the physician employs fluoroscopic guidance for the G-tube replacement you would report 49450(Replacement of gastrostomy or cecostomy [or other colonic] tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report)

Put These Tube Procedures on Your Radar

Most of the tube replacement presentations in your ED will feature PEG tubes, though there are a few other tube procedures you might encounter in your ED as well.

Cystomy tubes: On occasion, your ED physician might have to replace suprapubic cystostomy tubes. When this occurs, Berg says to choose one of the following codes, depending on encounter specifics:

• 51705 -- Change of cystostomy tube; simple
• 51710 -- ... complicated.

J tubes: Patients requiring jejunostomy tube (J tube) replacement might also present to the ED for treatment. These more delicate tubes often require radiologic visualization for safe replacement. If fluoroscopic guidance is employed you would report 49451 (Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).