Gastroenterology Coding Alert

Find out what codes include fluoroscopic guidance.

When your gastroenterologist deals with any of several types of gastrointestinal (GI) tubes (gastrostomy tubes, duodenostomy or jejunostomy tubes, cecostomy or other colonic tubes, and gastro-jejunostomy tubes), you should scrutinize how he carried out the procedure on the patient to determine the proper CPT codes.

GI tube procedures comprise three main types: initial tube placement, tube placement, and tube maintenance. Each provides a unique set of guidance that calls for different coding approach. Follow it to a T, and you'll always be treading safe waters. See what our experts have to say.

Pick Proper 'Initial' GI Tube Placement Code

If your gastroenterologist performed an initial, percutaneous insertion of a gastrostomy tube, without using an endoscope and including radiologic supervision and interpretation, use 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).

In this procedure, the gastroenterologist creates a puncture through the patient's abdominal wall from outside the body, and inserts a device under fluoroscopic or ultrasound guidance. This allows the physician to pull the stomach up to the abdominal wall and then insert the tube percutaneously without using an endoscope.

Hindsight: In the past, you would report this procedure using 43750 (Percutaneous placement of gastrostomy tube). But in 2008, CPT deleted this code. Its replacement, 49440, includes all of the components to place the tube, including the associated imaging procedures, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program.

Sample Op Note: Inflated air in the stomach via the nasogastric tube. Punctured the stomach above the colon under fluoroscopic guidance. Dilated the tract serially, and placed a GI tube using pull technique. Inflated the balloon; confirmed intragastric placement with contrast injection. Dressed the wound. In this case, you would use the all-in-one code 49440 on your claim.

Quick fact: In many regions, interventional radiologists primarily perform 49440. However, surgeons, gastroenterologists, and hospital intensivists may also carry out this procedure.

Similarly, 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) describes initial placement of a gastrostomy tube, but using an endoscope, and without fluoroscopic guidance. It is also known as percutaneous endoscopic gastrostomy (PEG). This tube placement procedure is primarily performed by gastroenterologists.

You should report other GI tube initial placement procedures based on the type of tube your gastroenterologist used. 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).

Important: Since no single code describes initial placement of a gastro-jejunostomy tube, you should first report the gastrostomy tube placement using 49440, then follow it up with 49446 (Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report), according to AMA instructions in CPT.

'Replacement' Gives a Different Hint

Sometimes, your gastroenterologist will perform GI tube replacement, which is commonly carried out by interventional radiologists. Turn to the following set of codes specific for this case:

Careful: Do not confuse 49450 with 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance). The latter describes gastrostomy tube replacement without imaging guidance.

Example: An ambulance brings in an elderly female with a dislodged G tube from the nursing home. 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. You would use 43760 to report this encounter, and not 49450.

Watch Your 'Maintenance' Procedures

For maintenance services, you should familiarize yourself with another set of codes, which includes:

Remember: Codes 49440-49442, 49450-49452, 49460, and 49465 all include fluoroscopic guidance.

Sample Op Note: Unclogged the J tube under fluoro guidance. Confirmed intrajejunal and intragastric placement with contrast injection. Flushed catheter; is ready for immediate use. Report 49460 in this case.