Gastroenterology Coding Alert

Reimbursement for percutaneous gastrostomy (PEG) tube placements performed by two gastroenterologists has become more difficult in the past year for many gastroen-terology practices. In response to what seems to be unannounced changes in payment rules at the carrier level, many practices have changed the codes or modifiers they use to report this procedure to ease their payment problems.

PEG tube placement is a multistep procedure that requires two sets of hands. A gastroenterologist performs an upper gastrointestinal endoscopy to locate the desired position along the wall of the stomach for the tube to be placed. Once the position is marked, an incision is made into the wall of the stomach. The PEG tube is then fed over the endoscope and held in place with a retention disk.

While a surgeon or a nonphysician practitioner such as a surgical nurse or a physician assistant can make the incision, it's usually done by another gastroenterologist. At Gastroenterology Consultants, a 10-physician practice in Milwaukee, some of the gastroenterologists feel comfortable working with a physician assistant, while others request another gastroenterologist to perform the procedure, according to Barbara Kallas, billing specialist for the practice.

"The physician assistants are approved to do the procedure by the state, but they don't get separately reimbursed," she says. "We will only bill for the gastroenterologist's services with 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube)."

The most common way of billing a two-physician PEG placement, regardless of the specialties of the physicians, is for each physician to bill 43246 with modifier -62 (Two surgeons) attached. This is the method recommended by the AMA in the Spring 1994 and February 1997 issues of CPT Assistant. When modifier -62 is used, each physician will receive 62.5 percent of the standard fee allowed by Medicare, according to the Medicare Carriers Manual (MCM) section 15046.

Some Medicare carriers, such as California's National Heritage Insurance Company, have indicated that they prefer modifier -80 (Assistant surgeon) when two gastroenterologists perform the PEG placement. The gastroenterologist who makes the incision into the stomach is considered the assistant surgeon, and he or she receives 16 percent of the standard fee allowed by Medicare, according to MCM section 15044. The gastroenterologist who performs the endoscopy bills 43246 without a modifier attached and receives 100 percent of the standard fee allowed by Medicare.

These more restrictive carriers usually allow modifier -62 only when a surgeon is involved. Because PEG placement is a surgical procedure, however, all physicians performing a PEG should be considered surgeons in this situation, argues Sandi Scott, CPC, CORT, director of coding at Mission Internal Medicine Group, a practice with four gastroenterologists in Mission Viejo, Calif.

Scott, who for many years has billed PEG placements performed by two gastroenterologists with modifier -62, believes that modifier -80 is inappropriate because each physician is performing a different task one is not assisting the other. "I decided that modifier -62 should be used by observing what the gastroenterologists did," she says. "They are doing two distinct procedures, which is what the CPT definition for modifier -62 calls for."

The Medicare Physicians Fee Schedule Database, which has fields indicating what procedures can be considered for cosurgery and assistant surgery, only makes the coding picture more confusing because it appears that the PEG placement is eligible neither for cosurgery nor assistant surgery reimbursement. The cosurgery indicator in Field 24 of the fee schedule for 43246 is 2, which means that cosurgeons are permitted. But MCM section 15900.2, which explains what the fee schedule fields mean, states that this only applies when the cosurgeons are from different specialties. The assistant surgery indicator for 43246 in field 23 is 0, which means there is no payment for assistant surgeons for this code unless documentation is submitted to establish medical necessity.

Last summer, Medicare announced in the Federal Register that it was examining its payment policies for cosurgery to make sure they properly reflected the work effort involved in providing these services. While no new rules were enacted regarding cosurgery, many gastroen-terology practices have noticed a change in payment polices at the local level and are having difficulty getting reimbursed with the codes and modifiers they previously used. Mary Brigham, billing manager for Gastroen-terology Associates in Williamsville, N.Y., noticed that her practice was no longer getting paid for the second gastroenterologist, who was billing 43246-62. For a while, she billed only 43246 so that at least the full value for the procedure was received.

Six months ago, she was advised by her Medicare representative to bill two different codes: 43750 (Percutaneous placement of gastrostomy tube) for the gastroenterologist making the incision and 43246 for the one performing the endoscopy. "We went to a four-hour Medicare seminar on modifiers where we were told that it was OK to bill two different codes for the PEG placements and that it was OK not to use a modifier," Bingham says. Since then she has had no problem getting reimbursement for the two codes.

When two gastroenterologists performed the PEG placement at Kallas' practice, she would bill 43246 and 43246-80. She noticed several months ago that payments had also stopped coming for the assistant surgeon, so she stopped billing for it all together. Recently she attended a seminar where she was advised to start using modifier -62 on her claims.

"Every year it seems that there's a change in the rules," she says. "But no one ever bothers to tell you that it's been changed."

Others who are having trouble getting paid are advised by Scott not to give up on their tried-and-true methods. "Medicare denies many things that are not legitimate to deny," she says. "You just have to appeal it. Maybe the carrier didn't look at the claim carefully."

Several other procedures involving PEG tube, other than its placement, require only one gastroenterologist. A PEG tube may deteriorate or become occluded, for example, and have to be changed. If the change is done manually, 43760* (Change of gastrostomy tube) should be reported. If it's done endoscopically, the removal of the old tube should be reported as an esophagogastroduo-denoscopy (EGD) with foreign-body removal with 43247, and the placement of the new tube with 43246. Some payers might require that modifier -51 (Multiple procedures) or -59 (Distinct procedural service) be appended to 43247 because it is the lesser-valued procedure and to distinguish the two services as distinct and separate.

PEG tubes may also be converted into a jejunostomy tube (J-tube). The PEG tube has been previously placed, and the more slender J-tube is passed through the PEG tube and into the stomach until it reaches the jejunum. Enteroscopy code 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube) should be used to report the J-tube conversion.

A PEG tube can be removed either endoscopically or manually, depending on the type of tube that was used. If the tube is removed endoscopically, 43247 should be reported, Scott says.

Frequently, however, the tube is removed manually during an inpatient hospital visit, Kallas says. There is no specific code for billing a manual removal, but it can be included in the E/M service provided. Kallas generally bills the removal as part of a low-level subsequent hospital care visit (99231-99233).

Scott also bills the removal as part of an E/M service but cautions that this can only be done when the gastroen-terologist performs a full evaluation of the patient that includes an interval history and a physical examination. The key component, medical decision-making, is met when the gastroenterologist decides that it is OK to remove the tube. "If the visit is straightforward, and the gastroenterologist just removes the tube, we don't bill anything," Scott explains. "But usually the gastroen-terologist will talk to the patients, ask them how they are doing and perform at least a minimal examination."