Gastroenterology Coding Alert

Hint: Look for inclusion of fluoroscopic guidance before selecting a code.

The use of gastrointestinal (GI) tubes is common in gastro practices, but that doesn’t mean it’s always straightforward to code when addressing tube placement, replacement, and maintenance. Each type of tube service has a unique set of coding rules, and the inclusion of radiological supervision can make your coding process even more complicated.

Carefully reviewing the documentation will be the key to coding accurately every time your provider performs a service related to a GI tube.

Check out These Initial Tube Placement Procedure Codes

In some cases, it may be necessary for the gastroenterologist to place a GI tube, which is typically done via a puncture through the patient’s abdominal wall from outside the body.

Scenario: Your gastroenterologist documents the following procedural details in the procedure report:

• Inflated air in the stomach via the nasogastric tube
• Punctured through the patient’s abdominal wall from outside the body under fluoroscopic or ultrasound guidance
• Dilated the tract serially, inserted a GI tube, allowing the stomach to be pulled up to the abdominal wall (pull technique)
• Inflated the balloon; confirmed intragastric placement with contrast injection without using an endoscope.

The all-in-one code is 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report). Note: This code does not include using the endoscope.

Similarly, 43246 (Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube) also describes initial placement of a gastrostomy tube. Unlike 49440, this code includes using an endoscope, but does not include fluoroscopic guidance. This is also known as percutaneous endoscopic gastrostomy (PEG).

Other types of GI tube initial placement procedures: You should report other GI tube initial placement procedures based on the type of tube your gastroenterologist used, which usually refers to the location where it was placed. For instance, percutaneous insertion of a duodenostomy or jejunostomy tube calls for reporting 49441 (Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report). For similar insertion of a cecostomy or other colonic tube, the appropriate code choice is 49442 (Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report).

If the physician doesn’t specify location in the procedure report, you should always ask so you can pinpoint the most accurate code.

Review the Codes for Tube Replacement

In some cases, the physician will replace an existing tube, in which case the initial placement codes would be inappropriate. Instead, the following set of codes are specific for cases of GI tube replacement procedures:

• 49450 (Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report) when the physician replaces a gastrostomy, cecostomy, or other colonic tube under fluoroscopic guidance
• 49451 (Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report) to report percutaneous replacement of a duodenostomy or jejunostomy tube
• 49452 (Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report) for percutaneous replacement of a gastro-jejunostomy tube.

Case scenario: Your gastroenterologist sees a 56-year-old male with a dislodged G-tube. The gastroenterologist orders a replacement G-tube to the bedside and places it through the well-established percutaneous tract. After placement, the physician aspirates gastric contents, confirming that the tube is safely within the stomach. The appropriate code to report this encounter would be 43762 (Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract) because no imaging was used and the gastrostomy tract was not revised.

Master Your Maintenance Procedures

There may be instances when your GI physician doesn’t place or replace a tube, but instead performs maintenance on it. You should use a separate set of codes to identify tube maintenance procedures, which includes:

• 49460 (Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report) if the physician removes any items from the tube
• 49465 (Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report) if a radiologist examines an existing GI tube via a percutaneous approach.

Don’t forget: If your gastroenterologist simply removes a tube and doesn’t replace it with anything, you won’t find a procedure code for it. Instead, you’ll report the appropriate E/M code (99202-99215) as appropriate based on the documentation. Likewise, if the physician clears a clogged tube at bedside without replacing it and without fluoroscopy, an appropriate E/M code is reported