Gastroenterology Coding Alert

Appropriate coding for tube placements and replacements depends on coders distinguishing whether the gastroenterologist performed the procedure manually or endoscopically. Further, understanding the different tube variations and applications can help limit coding problems.

 

 

Percutaneous endoscopic gastrostomy (PEG) tube placement is reported 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 Linda Parks, MA, CPC, lead coder with the 22-physician Atlanta Gastroenterology practice. 

Physician notes sometimes contain references to buttons"" PEG buttons or ""Mickey"" buttons. These are smaller" shorter tubes that are inserted through the tract in the skin of the abdomen that was created by a standard PEG tube explains Michael L. Weinstein MD of Metropolitan Gastroenterology Group in Washington D.C. and previous American Society for Gastrointestinal Endoscopy (ASGE) representative to the CPT Advisory Board. 

"PEG buttons are used to replace a standard PEG tube after several weeks or months when the original tube tract has matured " Weinstein says. "Therefore you usually code it as a PEG tube replacement (43760 change of gastrostomy tube).

"You also might see tube descriptions with ports balloons or bumpers " Weinstein adds. "They're all tubes. MIC and Bard are just some of the brand names." Placement of these shorter tubes is still coded with 43246. Changing PEG tubes of any kind should be reported with 43760.
 
An Alternative to PEG Tubes

 

Gastroenterologists also use percutaneous endoscopic jejunostomy (PEJ) tubes explains Thomas M. Deas Jr. MD of Gastroenterology Associates in Fort Worth Texas and chairman of the Practice Management Committee of the ASGE. This is a long tube that is passed through the PEG tube into the small bowel rather than the stomach.  

There are two ways to code the PEJ tube procedure. The patient may already have a PEG tube in place and the physician has to convert it to a PEJ tube by going beyond the duodenum. This method should be reported with 44373 (small intestinal endoscopy enteroscopy beyond second portion of duodenum not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube). If the patient does not have a PEG tube coders should use 44372 (... with placement of percutaneous jejunostomy tube) for the initial PEJ tube placement. 

Code 44500 (introduction of long gastrointestinal tube [e.g. Miller-Abbott]) refers specifically to the length of a tube Weinstein explains. Longer tubes are weighted at the end (with mercury for example) and are used when there is a gastrointestinal obstruction. 

"No other procedure needs to be performed with this " Weinstein says. "The tube position usually requires checking an x-ray -- a separate billable service -- and advancing or repositioning by a nurse or physician."

 

 

According to Deas technology in the gastroenterology field has developed at a faster pace than the coding process. Some of the new entries in the CPT manual for 2001 don't necessarily mean that the procedure is new he says just that code development is lagging somewhat behind.  

One new entry is 43240 (upper gastrointestinal endoscopy including esophagus stomach and either the duodenum and/or jejunum as appropriate; with transmural drainage of pseudocyst). This procedure uses a tube for drainage.

Before the new code was added you could report this procedure two ways according to Parks: 43235 (upper gastrointestinal endoscopy including esophagus stomach and either the duodenum and/or jejunum as appropriate) with modifier -22 (unusual procedural services) submitted with the operative notes or 43999 (unlisted procedure stomach) again submitted with the operative notes.

"When using these two codes you never knew how much the reimbursement was going to be " Parks notes. "Some insurance companies would not even pay for the unlisted code and others would not allow extra payment for the -22 modifier."

 

 

CPT 2001 introduced a code for insertion of a naso-gastric (NG) tube 43752 (naso- or oro-gastric tube placement necessitating physician's skill). This type of tube (usually a Dobhoff) runs from the nose to the stomach or further into the duodenum or jejunum explains Weinstein and can also migrate farther with peristalsis.  

For example a stroke patient may need an NG tube to provide sustenance. NG tubes are also used to aspirate in cases of intestinal obstruction Weinstein adds.  

NG tube placement can be performed by a nonphysician practitioner (NPP) if the procedure falls within the NPP's scope of practice. Circumstances such as a patient who is combative however would require physician intervention Weinstein says. Code 43752 is not to be used with critical care codes (99291-99292) or neonatal intensive care codes (99295-99298) according to CPT instructions. Code 43752 is one of the services already included in critical care when performed by the physician providing the care and it is an included procedure in the neonatal intensive care codes.

Parks has found that many insurers are not reimbursing for 43752. If a carrier does not cover this code Parks recommends billing a level-three E/M service (99213) instead. "Our doctors perform a normal office visit with history and physical examination of the patient both before and after placement of the tube " Parks explains. "That's how we meet a level-three criteria." 

 

 

Gastroenterologists use a highly technical procedure known as endoscopic retrograde cholangiopancreatography (ERCP) for both diagnostic and therapeutic purposes says Weinstein. ERCP (43260 endoscopic retrograde cholangio-pancreatography [ERCP]; diagnostic with or without collection of specimen[s] by brushing or washing [separate procedure]) is used to aid in the diagnosis of many diseases of the pancreas and also to remove gallstones stuck between the gallbladder and intestines. 

Several tube codes can be used with ERCP. Code 43267 (... with endoscopic retrograde insertion of nasobiliary or nasopancreatic drainage tube) should be reported when a nasobiliary tube/catheter is placed to access the bile duct usually for collection of drained material or instillation of medication for a prolonged time after a procedure. A sphincterotomy is not needed to place a nasobiliary drain. Nasobiliary drains can be removed without another procedure and are coded as an E/M service.

Code 43268 (... with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) should be used when tubes are placed in the bile duct or pancreatic duct to maintain drainage of secretions that are blocked for any reason (cancer stricture stone etc.). 

Multiple stents can be placed at the same setting and  usually require sphincterotomy. Temporary stents typically last four to nine months before becoming clogged and can only be removed during another procedure although some stents are permanent. 

Coders should report 43269 (... with endoscopic retrograde removal of foreign body and/or change of tube or stent) when the stent must be replaced because it is clogged and drainage is impeded. This requires snaring the old stent and withdrawing it from the patient and then reinserting a stent usually of the same size in a fashion similar to the original placement (43268).   

When additional stents or nasobiliary tubes are placed in the same duct they are not reimbursable using the same code twice. If two stents or tubes are placed at different sites (i.e. bile duct and pancreatic duct) then appending modifier -59 (distinct procedural service) will achieve partial reimbursement for the second stent or tube.

 

 

PEG tubes can be removed either endoscopically or manually depending on the type of tube used and the patient's condition. Some tubes are designed to be manually removed in the office. "Just grab and pull " Weinstein says. Other tube circumstances dictate endoscopic removal.

"Both buttons and tubes may require endoscopic retrieval when they can't be removed manually through the tract created in the abdomen " Weinstein explains.  "They can break leaving the inside portion within the stomach or possible abdominal wall trauma might be more than the physician wants to cause. If there is a concern about intestinal obstruction from the 'foreign body ' the tube or button can be snared during an endoscopy and brought out through the mouth."

Some gastroenterology practices bill a level-two E/M service (99212) for manual PEG tube removal. Weinstein explains that the key components for this E/M are minimal and describes which elements are included in the patient's medical record and how tube removal meets level-two criteria. "A quick statement as to the purpose of removing the tube should be included with the claim " he explains. 

"That's one element. Another element is an exam of the abdomen around the tube and condition of the tube tract after removal. No additional history or exam is needed necessary or typically performed. 

"A complicated removal is rare but might involve a longer visit because of pain and/or bleeding " Weinstein adds. In such cases the level of E/M service could go up based on time additional examination decision-making or treatment options.

The diagnosis code can be the original diagnosis code used for insertion. "I usually use feeding difficulty (783.3) and another code appropriate to the patient's current condition such as abdominal pain infection etc. I use multiple diagnosis codes with many procedures and visits sometimes up to four to fully describe the reasons " says Weinstein.

For some patients or with certain types of PEG tube removals Weinstein says it may be best to remove the device endoscopically to avoid trauma to the abdominal wall. This can be done prior to placement of a PEG button to change the apparatus prior to placing a jejunal feeding tube or to move the PEG site he explains. An exam is not needed except as required for conscious sedation used with endoscopy and an E/M visit on the same day would be unusual. 

If the only thing performed is removal of the original PEG tube Weinstein says he uses 43247 (... removal of foreign body). Code 43247 can be used to remove the PEG apparatus placed during the initial PEG insertion (43246) he further explains when that tube cannot be removed by directly pulling it through the gastrostomy tract that forms after several weeks.  

Some coders have used 43750 (percutaneous placement of gastrostomy tube) for removal and attached modifier -52 (reduced services) but this is a surgical code and its reimbursement for tube removal is erratic.