Gastroenterology Coding Alert

Radiologic supervision and endoscopic guidance call for different codes

Getting to know the whole story about your gastroenterologist's G-tube replacement procedure is what's going to keep you on the straight and narrow. Ignore the details, and you could report 43760 when you should be choosing a different code.
 
If a patient's gastrostomy tube (G-tube) suddenly malfunctions, he will likely be unable to get the liquids, nutrients or medications that he needs, creating an emergency. For this reason, many gastroenterologists often have to treat patients with malfunctioning G-tubes.
 
Who needs them? -G-tubes are necessary for patients who need enteric nutrition, or any patient unable to have any oral intake for a prolonged period of time,- says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers.
 
Physicians may also administer medications through G-tubes, say Elijah Berg, MD, FACEP, chief operating officer of Medical Reimbursement Systems Inc. in Stoneham, Mass.

Clogs in the Tube Cause Problems

So how does a G-tube malfunction? According to Pfaff, when the liquid (fluids, medication, enteric nutrition, etc.) passes through the G-tube, it can clog, kink, dislodge or malposition the tube, creating the need for a replacement.
 
For proper G-tube replacement claims, you check the physician's notes:
 
- for evidence of possible separate E/M services the gastroenterologist might provide along with the G-tube service.
 
- to see if the physician used contrast monitoring during the procedure.
 
- for evidence of radiologic supervision and interpretation during the procedure.

Only then can a coder choose the right G-tube code combination for the claim.

You May Need a Separate E/M

When the gastroenterologist replaces a G-tube, the contact usually involves a separate E/M, Berg says.
 
During this encounter, the physician is obligated to evaluate the patient for the presence or absence of an emergency medical condition, he says.
 
Patients with displaced or non-functioning G-tubes should have their hydration status and living situation evaluated, Berg says. Further, the physician should assess the appropriateness of the patient's current care and check if the patient missed any doses of medications.
 
-There is no cookbook answer as to what [E/M] level this could be,- Berg says.
 
For example: The gastroenterologist treats a nursing home patient in the emergency department with a displaced G-tube and evidence of dehydration. She performs a detailed history and physical exam, orders lab tests, and administers IV fluids for rehydration. Examination of the tube shows a significant clog. The gastroenterologist reviews the lab tests, rehydrates the patient and changes the G-tube. On the claim, you should:
 
- report 43760 (Change of gastrostomy tube) for the tube replacement.
 
- report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity) for the E/M service.
 
- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99284 to show that the E/M service was separate from the G-tube replacement.
 
Best bet: Don't assume the E/M level for any of your G-tube replacement patients. First, find out if the physician performed a separate E/M service. If she did, decide on the service level based on the notes she provides.

Use 43760 for the Same G-Tube

You should also use 43760 if the physician puts the same G-tube back into place. If your gastroenterologist treats a patient with a G-tube that has fallen out, and the gastroenterologist re-inserts, you can still report 43760. -Any re-insertion (either of the existing G-tube or of a brand-new tube) warrants coding of 43760,- Berg says.
 
So in most instances, you will report 43760 when your gastroenterologist replaces a G-tube.
 
There are two exceptions to this rule:
 
1. If the gastroenterologist needs contrast monitoring, or radiologic supervision and interpretation, to change a G-tube, report 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g. gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation) with modifier 26 (Professional component) attached, Berg says.
 
You should use 75984 when the physician needs radiologic confirmation of the tube placement due to technical difficulties associated with the patient's anatomy or the placement of the tube itself, Berg says.
 
2. If the physician needs to perform an endoscopy to evaluate co-existing complaints of pain or bleeding   or to determine whether there have been other complications from the tube malfunction, you should report 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or   jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).