Gastroenterology Coding Alert

Question: Can we bill for the removal of a PEG tube, or is it included in the E/M service? If not, which code should we use? South Carolina Subscriber Answer: How you code the removal of a percutaneous gastrostomy (PEG) tube is going to depend on two factors: why the tube is being removed, and whether there are complications in the removal and these factors can also determine whether you will be paid separately for the service. The reason for the removal of the tube is a relevant piece of information to how you code the service because you will code the removal based on whether the tube was subsequently replaced.

For example, a patient may present with an occluded tube, and the gastroenterologist removes the tube with the intention of replacing it with a new tube. You will need to code this removal and replacement with 43760* (Change of gastrostomy tube) if the PEG tube is replaced manually. Be sure the tube was removed and replaced using the same method if you use 43760. But if the PEG tube was replaced endoscopically, then you bill an EGD with foreign-body removal, coding the PEG replacement with 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube). On the other hand, if the tube is being removed without the intent of replacing it, the removal is considered included in the evaluation and management service, both inpatient and outpatient. When determining the level of the E/M service, you should not take into account the tube removal; rather, you should assign the level based on the standard components of history, examination and medical decision-making. The next factor you need to consider is whether there are any complicating circumstances surrounding the tube removal. For example, if the PEG tube breaks off during the removal, you are going to need to modify your coding and use foreign-body removal code 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body).

For other complications, the requirements call for reporting code 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) or code 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Because there is no code specifically for the PEG tube removal, you will have to find a code that best represents the gastroenterologist's services under any tube removal extenuating-circumstances codes.