Gastroenterology Coding Alert

Question: Our surgeon removed a PEG tube in the office and circled 43760 on the superbill, which our coder submitted. After the office manager read the documentation later, she argued that the PEG removal didn’t support the code reported. Is she right, and if so, what do we do?

Suercoder.com Subscriber

Answer: She is indeed correct. For an uncomplicated PEG tube removal performed in your office, you should report an outpatient E/M code (99212-99215).

You can use 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance) linked with diagnosis code Z43.1 (Encounter for attention to gastrostomy) if the gastroenterologist removed the PEG tube then placed another one (replacement). But if there’s no replacement, the E/M code is the way to go.

Since your practice already submitted the claim with 43760, you’ll have to contact the insurer, since you’re on track to receive what is likely a big overpayment. Medicare contractors will typically pay about $500 for 43760 if you perform it in the outpatient setting, whereas even the highest outpatient E/M code (99215) pays just $146. Therefore, if the payment has already been issued by the insurer, you’ll have to refund it and resubmit an amended claim.

CMS takes a strict view of providers’ obligations to return all overpayments, and failing to do so can result in civil money penalties, fraud investigations or even exclusion from the program. Most Medicare contractors have pre-written forms that you can fill out with the details of an overpayment. For instance, Part B MAC CGS Medicare has an “Overpayment Refund Form” on its website that you should complete and submit with refund checks so the insurer’s staff members know where to apply the payment.

If your insurer doesn’t offer such a form, you should send back the overpayment with a short letter to the carrier briefly stating how you identified the overpayment to include with your check. The letter should include the patient’s name, claim number, ID number, the document control number of the processed claim, the reason for the refund, and the amount that you’re sending back.