Gastroenterology Coding Alert

If you've pegged 2008 for being the year that will transform the way you report PEG tube services, you were right. Most of the CPT 2008 gastroenterology changes involve revised and new gastrostomy tube codes, and you've got little time to digest this information -- the new codes go into effect Jan 1.

Good advice: "It's a good idea to make a cheat sheet for your physicians," says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. "Along with telling your physicians about the changes, having this information on their chart area is usually much easier for them to remember."

Although CPT added nine new codes for insertion and other procedures involving gastrostomy and other tubes, you don't have to change how you normally report percutaneous endoscopic gastrostomy (PEG) tube placements.

If your gastroenterologist places a true PEG tube, your code of choice is 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) -- for now and into the next year. CPT 2008 makes no changes to this code.

What to look for: The op note for 43246 will describe an upper GI endoscopy with insertion of the gastrostomy tube. As the code descriptor specifies, placement of this type involves both an endoscopic and a percutaneous (through-the-skin) component. Generally, the purpose of the tube is either to provide nutrition (a feeding tube) or to act as a drain (in place of a nasogastric tube).

First, you should take note of this clarification on G-tube replacement code 43760 (Change of gastrostomy tube). CPT 2008 adds "percutaneous, without imaging or endoscopic guidance" to the code's descriptor. The language makes the code's appropriate use more clear, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program.

"My take on the new codes available for G-tube replacement is the following:

• You'll use 43760 for G-tube change with no radiologic supervision.

• You'll use 43760 with the newly revised code 75984-26 (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation; professional component) when the physician changes the G-tube with contrast.

• You'll use code 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) when your physician changes (replaces) the tube under fluoroscopic guidance," Parks says.

CPT 2008 also introduces several new codes for maintenance of gastrostomy tubes. "A surgeon might use these codes if the tubes weren't placed endoscopically," says Kathleen A. Mueller, RN, CPC, CCS-P, CMSCS, a healthcare consultant in Lenzburg, Ill.

Keep your eye open to documentation supporting:

Note: Code 49460 covers the mechanical removal of obstructive material from a gastrostomy or any other type of tube. And 49465 covers contrast injection(s) for radiological evaluation of an existing tube, including image documentation and report.

When the gastroenterologist deals with a tube that is already out of the patient and needs to be reinserted, you've got three new codes. These three new codes cover insertion for:

• gastrostomy (49440, Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report)

• duodenostomy or jejunostomy (49441, Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report)

• cecostomy or other colonic tubes (49442, Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).

Note this fluoro deletion: CPT deletes 74350 (Percutaneous placement of gastrostomy tube, radiological supervision and interpretation) and 43750 (Percutaneous placement of gastrostomy tube). The AMA now includes RS&I in the new percutaneous gastrostomy tube placement code 49440. Code 43246 replaces 43750.

Also: New code 49446 (Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) will come in handy when your physician converts a gastrostomy tube to a gastro-jejunostomy tube.

If you are now billing 82272 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, single specimen [e.g., from digital rectal exam]) for the annual fecal occult blood screening test, CPT has revised the code to make it clear that you should not report this code for a screening test: Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening.

The only two CPT codes that you can use for the screening fecal occult blood test are 82270 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening [i.e., patient was provided three cards or single triple card for consecutive collection]) or 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations). The immunoassay test may be physician-collected (except on a Medicare patient), but the patient must collect the guaiac test specimen herself.