Gastroenterology Coding Alert

Question: An established patient comes to the office complaining of rectal bleeding. The physician performs gastric aspiration, noting no blood. How should I report this case?


Michigan Subscriber

Answer: In this case, report 91105 (Gastric intubation, and aspiration or lavage for treatment [e.g., for ingested poisons]).

Previously, you could have used 43752 (Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance [includes fluoroscopy, image documentation, and report]), but this code now includes fluoroscopic guidance.

Physicians perform gastric lavage procedures to determine if a patient has active bleeding from the stomach, and the gastroenterologist may place the tube either orally or nasally. In a case like this, she would probably insert the tube through the nose.

Make sure there is proper documentation and a procedure note to reflect the medical necessity for the physician's involvement.

Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.