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Gastroenterology Coding Alert

Knowing Coding Variances Keys PEG Payments

Published on Sat Nov 27, 2004

 If a carrier wants modifier -80 on a PEG placement claim, will you be ready?

One thing is certain about PEG tube placements: You need two sets of hands to perform the procedure.  However, reimbursement will depend on whose hands are helping the primary physician: You use different reporting methods depending on the qualifications of the secondary personnel.

There are also those pesky variances in state local medical review policies (LMRPs) and the rules of each private insurance carrier, which may differ from the standard reporting methods.

Common wisdom holds that there are three different ways to report PEG placement; which one you should use will depend on the situation. Read on for advice on the three ways to code the procedure - and when to use each reporting strategy.

Modifier -62 Most Commonly Used With 2 Doctors

When the gastroenterologist places a PEG tube with another gastro's help, you'll most likely report the procedure using modifier -62 (Two surgeons).

Example: Gastroenterologist A is the primary caregiver for a patient with severe weight loss. He goes to the hospital to meet the patient, who is weak from starvation. With the help of Gastro B, Gastro A inserts a PEG tube. In this instance, you should:

 

  • report 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) for the PEG placement.
     
  • report ICD-9 code 994.2 (Effects of hunger) with 43246.
     
  • append modifier -62 to 43246 to show that two gastros performed the insertion.

    Remember: Both gastros should send a claim with the same code and modifier. Also, keep in mind that you should only use modifier -62 if the physicians are reporting the same CPT code.  If each doctor can represent his work with a separate CPT code, skip the modifiers.

    Some Prefer Modifier -80 for 2-Gastro Placement

    While most Medicare carriers want modifier -62 attached to PEG placement codes when two physicians perform the procedure, a few carriers may prefer that you  append modifier -80 (Assistant surgeon) to 43246.

    The major difference between modifier -62 claims and modifier -80 claims? When reporting PEG placements with modifier -80, only the assistant gastro should append the modifier. The primary gastro doesn't need to use a modifier when he reports 43246.

    Do It This Way: If your payer wants modifier -80 on a PEG placement claim, the gastro performing the endoscopic portion of the procedure should report 43246 without a modifier.

    The assistant gastro should report 43246 with modifier -80 attached to show she was assisting the primary gastro. The assistant surgeon in this scenario will receive a portion of the normal payout for 43246. (In PEG placement procedures, the assistant surgeon is the gastro who prepares and treats the incision into the abdomen.)

    Filing claims with modifier -80 is not a common practice, but if you're not absolutely sure the payer accepts modifier -62 when two gastroenterologists place a PEG tube, call to check - they might want you to use modifier -80.

    When NPP Helps, Report 1 Code

    The good news: Now more than ever before, gastroenterology offices have qualified nonphysician practitioners (NPPs) who are rightfully allowed to act as the assistant when a gastro places a PEG tube.

    At Gastroenterology Associates of Evansville, Ind., there is an NPP who can assist the physician during a PEG placement, says Sherri Brasher, insurance/billing specialist at the practice.

    The bad news: Your office will receive no reimbursement for the NPP's work in the assistant role. If your gastro performs PEG placement with an NPP helping, report only 43246.

    Removal Method Affects Coding

    When your gastroenterologist takes the PEG tube out, you have two coding options. To code the removal, you'll need to know how he removes the tube.

    Most frequently, the doctor will remove the PEG tube endoscopically, which is reported with 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body).
     
    Exception: If the gastro removes the PEG tube using a non-endoscopic method, you cannot report 43247 - but you may be able to report an E/M service.

    If the gastroenterologist removes the PEG tube without an endoscopic procedure, the coding scenario would be subjected to either the 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) criteria or the 99231-99233 (Subsequent hospital care, for the evaluation and management of a patient ...) inpatient criteria.

    "For the most part, our doctors only charge for an E/M service when removing PEGs," Brasher says.

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