Gastroenterology Coding Alert

If your gastroenterologist places a feeding tube into the small bowel instead of the stomach, you need to make sure you recognize the difference between PEG and PEJ tube coding to receive appropriate reimbursement.

Various questions continue to arise in the coding world regarding the confusion in coding for PEG and PEJ placement or removal. Take a look at some frequently asked questions to see if you know how to decipher tube placement notes from the gasteroenterologist.

Percutaneous endoscopic gastronomy (PEG) tubes are essentially feeding tubes used with patients who are unable to consume sufficient calories to meet metabolic needs. Physicians use this technique most often with patients who have impaired swallowing, neoplasms of the esophagus or larynx, and other catabolic conditions.

If needed, due to repeated aspiration of nasogastric tube feedings or other problems, the physician can modify the PEG technique to allow transpyloric placement of a jejunostomy tube at the time of the initial procedure or at a later time. The main difference is that the physician inserts the PEG tube percutaneously into the stomach with an endoscope, while he inserts the PEJ (percutaneous endoscopic jejunostomy) tube into the intestine to the jejunum, says Margaret Lamb, RHIT, CPC, Great Falls Clinic, Great Falls, Mont.

You report a PEG tube placement with 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube), says Stephanie Goodfellow, billing supervisor for Mid-America Gastro-Intestinal Consultants in Kansas City, Mo.

You may be confused when the doctor's notes refer to "buttons" PEG buttons or "Mickey" buttons. These are smaller, shorter tubes that the physician inserts through an established tract in the skin created by the standard PEG tube. The physician uses PEG buttons to replace a standard PEG tube after weeks or months when the original tube tract has matured. Therefore, you should report it as a PEG tube replacement, 43760* (Change of gastrostomy tube), Goodfellow says.

You might see tube descriptions that mention ports, balloons or bumpers. These are all tubes, and terms such as MIC and Bard are simply brand names. You always code initial placement of the tubes with 43246, and subsequent changes with 43760.

A PEJ tube is a longer tube that the physician inserts through the PEG into the small bowel rather than the stomach. Two scenarios could affect your coding.

Say the patient already has a PEG tube in place, and the physician has to convert it to a PEJ tube by going beyond the duodenum. According to Lamb, you should code this procedure with 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube).

On the other hand, say the patient does not have a PEG tube already in place. You should use 44372 (... with placement of percutaneous jejunostomy tube) for the initial PEJ tube placement, Lamb says.

If you see a term such as "Miller-Abbott" tube in the doctor's notes, you know he is placing a specific type of nasogastric tube that is longer than others. You use 44500 (Introduction of long gastrointestinal tube [e.g., Miller-Abbott] [separate procedure]) for this type of procedure. Code 44500 refers specifically to the length of the tube. Longer tubes are weighted at the end and used when there is a gastrointestinal obstruction.

The key to this question is in the technique used to remove the apparatus. Gastroenterologists can remove PEG tubes either endoscopically or manually, depending on the type of tube and the patient's condition. Certain types of tubes dictate endoscopic removal, while others are designed for manual removal in the office. "If you are removing a PEG tube, you would use only an E/M, since this is usually done manually in the office and there is no procedure code to reflect this," Lamb says.

You should code to the level that your documentation and medical decision-making support. Usually, you will only be justified to bill for a low-level E/M code, such as a 99212 (Office or other outpatient visit ... established patient), Goodfellow says.

Depending on the placement or other problems, the gastroenterologist may need to remove the tube endoscopically, Goodfellow says. This can be done prior to placement of a PEG button, to change the apparatus prior to placing a PEJ tube, or to move the PEG site. In cases of endoscopic removal, an exam is not required, so an E/M visit on the same day would be unusual.

An example given by Lamb is when the physician needs to remove the PEG tube endoscopically because it has become dislodged or embedded in the stomach. When the physician only performs the removal of the original PEG tube, you should report 43247 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with removal of foreign body), she says. You can use 43247 when the gastroenterologist removes the PEG apparatus placed during the initial insertion (43246) because the tube could not be removed manually by directly pulling it through the gastrostomy tract that forms after several weeks.

You may have heard that you should report 43750 (Percutaneous placement of gastrostomy tube) with modifier -52 (Reduced services). However, this is a surgical code, and reimbursement for this code for tube removal is not accepted.