Gastroenterology Coding Alert

There's more than one way to code a PEG tube placed by more than one gastroenterologist and with the increasing difficulty of getting reimbursed for four hands working on one placement, it's a good idea to be familiar with all of your options.

To place a PEG tube, one physician 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 then makes an incision at that position into the wall of the stomach. And finally, the PEG tube is put in place and secured with a retention disk.

Here are three methods of coding PEG tube placements, some more widely accepted than others. 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, CCP, coding specialist for GI Diagnostics Endoscopy Center in Marietta, Ga.

The 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 cosurgeons, indicated by the number 2 in Field 24 of the fee schedule. Also, this method of coding joint PEG-tube placement was recommended in the CPTAssistant, establishing 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 surgeon's services. One practice may not code the surgery as a cosurgery and may choose a code for only its physician's work rather than choose the code that represents the physicians'combined efforts with modifier -62, for example. Both surgeons 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 type of physician can be considered a surgeon, and some payers differ on whether gastroenterologists are considered surgeons.

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.

The rules. When coding a PEG-tube placement by two gastroenterologists using modifier -80, 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 gastroen-terologist will be paid 100 percent of the allotted fee according to the MPFSD. 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, according to the MPFSD, payment is restricted for assistants at surgery for procedure 43246 unless documentation is submitted that establishes medical necessity for the assistant surgeon.

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 Jill Barron, coding specialist for Gastroenterology Associates of Cleveland in Ohio. She chooses to use 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," Barron 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.