Gastroenterology Coding Alert

Nugget: Code the insertion or removal of PEG tubes based on whether they were placed endoscopically, manually or with the aid of a fluoroscope.

The codes used to report procedures involving percutaneous gastrostomy (PEG) tubes are scattered among the upper gastrointestinal, stomach and small bowel sections of the CPT manual. Gastroenterologists who are reporting the placement, change or removal of a PEG tube need to use a code that properly identifies whether the service was done endoscopically, manually or with the aid of a fluoroscope.

PEG tubes are used to help patients with eating and swallowing problems. They are usually placed endoscopically by the gastroenterologist, according to John Lowe, MD, a gastroenterologist in Salt Lake City. The endoscopy is done to locate the desired position of the tube along the wall of the stomach. Once the position is marked, an incision is made in the wall of the stomach. A guidewire is inserted through the incision and captured by the endoscope. The PEG tube is then fed over the guidewire and held in place with a retention disk. Although Lowe does his PEG tube placements with the aid of a nurse, he notes some gastroenterologists may have a surgeon or another gastroenterologist assist with making the incision.

The PEG tube placement also can be done with the aid of a fluoroscope instead of through endoscopy, Lowe says. While a gastroenterologist could do either the fluoroscope method or the endoscopic placement of the tube, most of the time a radiologist will handle the fluoroscopy, he notes.

Coding for PEG Tube Placement

The endoscopic placement of a PEG tube should be reported with 43246 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube), according to Alena Logan, CPC, director of physician practice consulting for AmSurg Corp., the owner and manager of ambulatory service centers in partnership with physicians across the country. If a surgeon or another gastroenterologist assists the gastroenterologist, each should report 43246 with modifier -62 (two surgeons) attached. But they each probably will receive less than the standard fee for the PEG placement. Sections 4828(C.6) and 15046 of the Medicare Carriers Manual state that each physician involved in a co-surgery procedure will receive 62.5 percent of the fee schedule amount.

Although the CPT Assistant in its spring 1994 and February 1997 issues directs gastroenterologists to use modifier -62 when reporting a two-physician PEG placement, some coders indicate that their payers require a different modifier, such as -80 (assistant surgeon). In that situation, section 15044 of the Medicare Carriers Manual states that payment for assistant-at-surgery services performed by physicians will equal 16 percent of the amount otherwise applicable for the global surgery.

A PEG tube placement done with the aid of a fluoroscope, also referred to as a surgical PEG placement, should be reported with 43750 (percutaneous placement of gastrostomy tube), says Logan. If the gastroenterologist handles the fluoroscopy and does the interpretation, he or she also may report 74350 (percutaneous placement of gastrostomy tube, radiological supervision and interpretation), otherwise that code is reported by the radiologist.

Manual Removal Included in E/M Service

A PEG tube can be removed either endoscopically or manually, depending on the particular type of tube that was used, according to Lowe. Some tubes are designed so that they can be pulled out in the office, he explains. However, a Ponsky-type tube requires an endoscopic removal.

If the tube is removed endoscopically, 43247 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body) should be reported, Lowe says.

Frequently, the tube is removed manually during an inpatient hospital visit, according to Logan. This also can be done in an outpatient setting, where the tube will be pulled out. The manual removal probably should be included in the evaluation and management (E/M) service provided and not reported as a separate procedure, Logan says, even though the gastroenterologist removing the tube may not be the same one who inserted it.

The level of E/M service thats billed will depend on the standard components of history, examination and medical decision-making, she explains. If the tube is dislodged, then that will probably be the patients chief complaint and may require an examination.

In addition, the billing requirements for a manual removal may vary from payer to payer. Logan has heard that some payers will reimburse code 43750 with modifier -52 (reduced services) attached to it. But gastroenterologists should check with their local payer before reporting 43750-52 to make sure this is an acceptable billing.

Editors note: Code 43750 has a global period of 10 days, which means that any E/M services related to the procedure that are performed for the patient within that period cannot be billed separately.

Use Two EGD Codes for Endoscopic Procedures

The PEG tube also may have to be changed because it has deteriorated or become occluded, and again the code used to report the procedure will depend on whether it is done manually, endoscopically or with aid of a fluoroscope. Frequently, the change can be done manually, says Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 21-physician practice. Manual PEG tube changes should be reported with 43760 (change of gastrostomy tube). The same code also should be used if the change is done with the aid of a fluoroscope. If the gastroenterologist handles the fluoroscopy and does the interpretation, 75984 (change of percutaneous tube or drainage catheter with contrast monitoring, radiological supervision and interpretation) also should be reported.

The tube also may be changed endoscopically, which means that an upper gastrointestinal endoscopy is done to remove and replace the PEG tube. Gastroenterologists, however, should not use a combination of 43760 and 43246 or 43247 to report an endoscopic removal, according to Logan, because 43760 is bundled into both of the endoscopic codes by the Correct Coding Initiative. Medicare will reimburse only the lesser-valued service, which in this case is 43760, and the gastroenterologist will not receive payment for the endoscopy.

Instead, the endoscopic removal of the PEG tube should be reported with 43247 and the replacement with 43246, recommends Parks, who also would add modifier -59 (distinct procedural service) to 43247 because it is the lesser-valued service of the multiple-procedure combination. Some payers might require modifier -51 (multiple procedures), both modifier -51 and -59, or no modifier at all in this same situation, so gastroenterologists may want to check with their payers for specific billing instructions for this procedure.

Coding for a PEG Tube Conversion

PEG tubes also may be converted into a jejunostomy tube (also referred to as a j-tube). The PEG tube already will have been in place, according to Lowe. A more slender tube is then passed through the PEG tube, into the stomach and through the pyloric channel and duodenum into the jejunum, he explains. The code to report that procedure is 44373 (small intestinal endoscopy; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube). If the jejunostomy tube needs to be repositioned either manually, surgically or endoscopically then code 43761 (repositioning of the gastric feeding tube, any method, through the duodenum for enteric nutrition) should be used.

A j-tube also can be placed through a percutaneous puncture in the abdomen and under endoscopic guidance instead of through a PEG tube. Code 44372 (small intestinal endoscopy; with placement of percutaneous jejunostomy tube) should be used to report this surgical placement of the j-tube.