Gastroenterology Coding Alert

Question: Is there a specific CPT^® code for closure of an old G-tube site? The notes outline a procedure performed on a 12-month-old patient presenting with a G-tube site that has not spontaneously closed. The note mentions the use of general anesthesia and incision around the site, and that the stomach was successfully returned to the abdomen and subcutaneous tissue was closed. No apparent complications.

Ohio Subscriber

Answer: This encounter calls for CPT^® code 43870 (Closure of gastrostomy, surgical). Gastrostomy is the surgically created opening in the stomach for insertion of a feeding tube (G-tube).

According to the lay term description for 43870 in AAPC’s online coding tool, Codify (https://www.aapc.com/codify/ contact.aspx): “After the induction of general anesthetic, the provider makes an incision around the gastrostomy site and carries it down through the skin and subcutaneous tissue with sharp dissection. He frees up the tract and the stomach and places stay sutures on either side of the tract. The tract is amputated. He then closes the intervening stomach with interrupted Lembert Nurolon^® sutures. He closes the fascia and skin in layers and applies a dressing.”

When in doubt, though, it’s always best to query the provider. Thorough documentation is essential, not only for providing a clear picture of a patient’s healthcare through the years, but also for medical coders who need to submit clean, compliant claims. It’s always wise to ask the provider for more information if you find yourself unable to code an encounter with the information in the patient record. The provider has likely done this surgery many times and, therefore, may write in unfamiliar shorthand or leave out details, but writing complete notes is still best practice.