Gastroenterology Coding Alert

PEG tube placements are used when patients are unable to eat or swallow, according to Kathy Anderson, RN, the director of nursing and plant manager of the Indianapolis Endoscopy Center, an ambulatory surgical center serving four gastroenterologists. She believes most of the patients receiving the feeding tube are in a debilitated and fragile state and are often stroke victims.

The placement procedure has multiple steps that require two sets of hands. The gastroenterologist first performs an upper gastrointestinal endoscopy, which is done to locate the desired position for the tube along the wall of the stomach. Once the position is marked, an incision is made into the wall of the stomach. The PEG tube is then fed over the endoscope and held in place with a retention disk.

Two Physicians Not Required

The source of the coding confusion for PEG tube placements comes from the shift away from using a gastroenterologist and a surgeon to perform this procedure toward the less expensive combination of a gastroenterologist and a nurse or other technician. If a nurse or technician is helping with the placement, the gastroenterologist locates the desired position of the tube before handing the scope over to his or her assistant. The gastroenterologist then makes the incision and puts the tube into place.

When PEG tubes first came out, it was believed that the procedure was fraught with danger that a nurse could not take care of, says Anderson, adding, in many hospitals, the accepted practice is still to have one surgeon and one gastroenterologist perform the procedure.

She adds, however, now the feeling among many is that this is easy. Why do we need another doctor in the room?

Two Coding Situations

The Health Care Financing Administration (HCFA), which administers Medicare, must have been thinking the same thing because it does not reimburse fully for the services of two physicians for this procedure.

Referring to the CPT Assistant (Spring 94), Pat Stout, CMT, CPC, and a consultant to the American College of Gastroenterologists, outlined two national standards for coding a PEG tube placement:

1. One gastroenterologist, one nurse. Use code 43246 (endoscopy with directed placement of percutaneous gastrostomy tube) without a modifier. The physician will receive 100 percent of the allowed amount. There is no extra reimbursement for the services of the nurse.

2. Two physicians (two gastroenterologists or one gastroenterologist and one surgeon). In this situation, first list 43246-62 (modifier -62, two surgeons), which represents the upper gastrointestinal endoscopy done by the gastroenterologist. Then list 43246-62 again to cover the making of the incision by the surgeon or second gastroenterologist. Each physician will receive 62.5 percent of the allowed amount. Total reimbursement should be 125 percent.

Local Carrier Option

Unfortunately, that national standard is not followed everywhere, claims Stout, because HCFAs policy also allows local Medicare carriers the option of paying for less than 125 percent of the allowed reimbursement for a PEG placement. Especially in the case where two gastroenterologists perform the procedure, the local carrier may require that the -80 modifier (assistant surgeon) be appended to the second physicians code instead of the -62 modifier. When the -80 modifier is used, the first gastroenterologist will receive 100 percent of the allowed reimbursement and the second gastroenterologist will receive 16 percent.

Manually Placing and Changing Tubes

Another area of confusion comes with the use of code 43750 (percutaneous placement of gastrostomy tube), which gastroenterologists will sometimes use instead of 43246.

Code 43750 should only be used when a PEG tube is being placed manually and never when it is endoscopically placed, according to Stout, a frequent speaker at seminars by the American Academy of Professional Coders. She cites that an appropriate use of this code is when a patient has
the tube out and the gastroenterologist manually puts it
back in place.

PEG tubes also may need to be replaced because theyve been damaged or have dissolved inside the patient. While Medicare will not reimburse for a removal and replacement procedure, private insurers often do. To code for that situation, Stout recommends first listing the code 43215 (endoscopy with removal of foreign body) and then listing 43760 (change of gastrostomy tube) with the -51 modifier (multiple procedures) appended.

Due to local carrier policies, PEG tube placement is one of those procedures where the correct coding methods can vary significantly, cautions Stout, who advises gastroenterologists to find out exactly what their state requires.

Even though the AMA publishes the national standard, she explains, billing and claims processing differs tremendously from state to state. Each gastroenterologists office should contact in writing its state Medicare office for specific coding instructions on two-man PEG placements with physicians of the same or different specialties.