Gastroenterology Coding Alert

When reporting a percutaneous endoscopic gastrostomy (PEG) tube placement involving two physicians, you've got three options, some of which are more widely accepted than others. Break them down according to their pros and cons and see where you stand.

Scenario: To place a PEG tube, one gastroenterologist performs an upper gastrointestinal endoscopy to locate the desired position along the wall of the stomach for the tube to be placed. The second physician, a surgeon, then makes an incision at that position into the wall of the stomach. And finally, a retention disk puts the PEG tube in place and secures it. How should you report this?

Advice: Because there is such discrepancy from state to state on how this service should be coded, you're going to need to have more than one trick up your sleeve.

Many coders turn to modifier 62 (Two surgeons) to code a two-physician percutaneous gastrostomy (PEG) tube placement (43246, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube).

"In Georgia, there's only one acceptable way to code a PEG placement by more than one physician, and that is to use modifier 62," says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.

Rules: To use modifier 62, each surgeon must perform a distinct part of one procedure and must account for that operative work by appending modifier 62 to the code that best represents the service provided.

The pros: According to the Medicare Carriers Manual (MCM), section 14046, each surgeon will receive 62.5 percent of the Medicare Physician Fee Schedule Database fee indicated for their service, Parks says.

Another benefit of using modifier 62 is the indication in the Medicare Physician Fee Schedule Database that code 43246 may be performed by co-surgeons, indicated by the number 2 in Field 24 of the fee schedule.

Also, in the past, CPT Assistant recommended this method of coding joint PEG-tube placement and therefore established this method as one of the most widely accepted means of coding for this service.
The cons: One potential disadvantage to using modifier 62 is having to coordinate the claims for each provider's services. One practice may not code the surgery as a co-surgery and may choose a code for only its surgeon's work rather than choose the code that represents the surgeon and gastroenterologist's combined efforts with modifier 62, for example. Both providers have to use modifier 62 to report the service for the claim to be processed properly.

Another potential drawback is that some carriers may have restrictions on what constitutes a surgeon.

Some Medicare carriers and private payers may specify that you have to code dual-physician PEG-tube placements by indicating one physician as the assistant, especially when two gastroenterologists perform the PEG-tube placement.

Be sure to check with your carrier before using modifier 80 (Assistant surgeon), Parks warns coders. Very few carriers, if any, will approve the use of this modifier for a joint-gastroenterologist PEG-tube placement, she says.

Rules: When you use modifier 80 for coding a PEG-tube placement by two gastroenterologists, the assistant surgeon is the gastroenterologist who handles the preparation and treatment of the incision into the abdomen. Both the primary physician and the assistant should report the same procedure code.

The pros: The good news is that the primary gastroenterologist will be paid 100 percent of the allotted fee. Also, to be reimbursed for claims using modifier 80, you are not typically required to submit additional documentation.

The cons: The bad news is that the assistant surgeon will receive only 16 percent of the amount otherwise applicable for 43246. Also, payment is restricted for assistant surgeons for procedure 43246 unless you submit documentation that establishes medical necessity for the assistant surgeon.

Take Caution Using 2 Procedure Codes

Depending on the carrier, you may have the option of using separate codes to represent the services provided by two physicians who place a PEG tube, says a coder for a gastroenterology specialist in Cleveland. She uses 43750 (Percutaneous placement of gastrostomy tube) for the gastroenterologist who makes the incision and 43246 for the gastroenterologist who performs the endoscopy.

"This is the only way we can get paid for the PEG-tube placement," the coder says.

However, this is not a widely accepted coding practice, and some Medicare carriers have written policies against using 43246 and 43750 to represent a joint-surgeon PEG-tube placement. So it is imperative that you check with your carrier before using this method of coding.