Gastroenterology Coding Alert

Keep a sharp eye out for type of tube, kind of placement and inclusion of fluoroscopic guidance.

When you get ready to code gastrointestinal (GI) tube procedures, you need to break them down into three categories:

• Initial tube placement
• Tube replacement
• Tube maintenance.

Inclusion of radiological supervision or not, each of the parameters provide a unique set of guidance which requires a different coding approach. Carefully following every aspect of the guidelines is the key to safe and efficient coding.

Check Out These Initial Tube Placement Procedure Codes

The physician performs this procedure through a puncture through the patient’s abdominal wall from outside the body.

Scenario: Your gastroenterologist performs the following procedural details as described in the procedure report:

• Inflated air in the stomach via the nasogastric tube
• Punctured through the patient’s abdominal wall from outside the body under fluoroscopic or ultrasound guidance
• Dilated the tract serially, inserted a GI tube, allowing the stomach to be pulled up to the abdominal wall (pull technique)
• Inflated the balloon; confirmed intragastric placement with contrast injection without using an endoscope.

The all-in-one code is 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report). Note: This code does not include using endoscope. 

Similarly, 43246 ( Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube ) also describes initial placement of a gastrostomy tube. Note: This code includes using an endoscope but does not include fluoroscopic guidance. This is also known as percutaneous endoscopic gastrostomy (PEG). 

Other types of GI tube initial placement procedures: You should report other GI tube initial placement procedures based on the type of tube your gastroenterologist used. For instance, percutaneous insertion of a duodenostomy or jejunostomy tube calls for reporting 49441 (Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report). For similar insertion of a cecostomy or other colonic tube, the appropriate code choice is 49442 (Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).

Note: Because no single code describes initial placement of a gastro-jejunostomy tube, you should first report gastrostomy tube placement using 49440, followed by 49446 (Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report), according to AMA instructions in CPT®.

Review the Replacement of Tube Procedure Codes

The following set of codes are specific for cases of GI tube replacement procedures:

• 49450 (Replacement of gastrostomy or cecostomy [or other colonic] tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) when the physician replaces a gastrostomy, cecostomy, or other colonic tube under fluoroscopic guidance;
• 49451 (Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) to report percutaneous replacement of a duodenostomy or jejunostomy tube;
• 49452 (Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) for percutaneous replacement of a gastro-jejunostomy tube.

Alert: Code 49450 should not be reported with 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance). The absence of imaging guidance in the latter, distinguishes its use from 49450, which includes fluoroscopic guidance including contrast injection[s].

Case scenario: An ambulance brings in a middle-aged male with a dislodged G tube from the nursing home. The gastroenterologist orders a replacement G-tube to the bedside and places it through the well-established percutaneous tract. After placement, the physician aspirates gastric contents, confirming that the tube is safely within the stomach. The appropriate code to report this encounter would be 43760 because no fluoroscopic guidance has been performed.

Master Your Maintenance Procedures

You should use a separate set of codes to identify tube maintenance procedures, which includes:

• 49460 (Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy [or other colonic] tube, any method, under fluoroscopic guidance including contrast injection[s], if performed, image documentation and report) for mechanical removal of obstructive material by any method (gastrostomy or any other type of tube); and
• 49465 (Contrast injection[s] for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy [or other colonic] tube, from a percutaneous approach including image documentation and report) if a radiologist examines an existing GI tube via a percutaneous approach.

Important: In all procedures that specify fluoroscopic guidance, relevant codes are 49440-49442, 49450-49452, 49460, and 49465.

Check out the following chart to make your GI tube procedure code selection easy: