Gastroenterology Coding Alert

Question: The gastroenterologist meets an established patient in the hospital to treat a malfunctioning gastrostomy tube (G tube). The gastroenterologist inserted the tube three weeks ago, and notes indicate that it just "popped out of place." After a level-two E/M, the gastroenterologist removes the old tube and installs a new one; to ensure proper placement, he uses contrast monitoring during the re-insertion. Is the monitoring part of the G tube placement, or can I code it separately?

Florida Subscriber

Answer: You should choose a single code for the replacement and the monitoring. On the claim, report the following:

• 49450 (Replacement of gastrostomy or cecostomy [or other colonic] tube, percutaneous, under fluoroscopic guidance including contrast injection[s]; image documentation and report]) for the replacement

• modifier 26 (Professional component) appended to 49450 to show that you are only coding for your physician's role in the monitoring

• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99212 to show that the E/M and G tube replacement were separate services

• 536.42 (Mechanical complication of gastrostomy) appended to 49450 and 99212 to represent the malfunction.

When your gastroenterologist performs a procedure using the hospital's equipment, you must append modifier 26 to the code. This ensures that the gastroenterologist is coding only for his services, not the equipment.