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 [...]