Gastroenterology Coding Alert

Question: Our gastroenterologist removed a percutaneous endoscopic gastrostomy (PEG) tube in the office, and we haven’t figured out how to code it yet. Can you advise?

Arkansas Subscriber

Answer: The appropriate code choice would depend on whether the physician had to use an incision to remove the PEG tube. You wouldn’t code a non-incisional PEG removal done in an office setting because CPT^® bundles PEG tube removal into the E/M codes. Therefore, for a non-incisional PEG tube removal, you’ll report the most appropriate E/M code based on the documentation (typically 99201-99215).

There are, however, some caveats to this advice. This only applies if the physician performs a removal rather than a replacement. In cases when a replacement is performed, you can use 43762 (Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract), assuming the gastrostomy tract did not require revision.

In other cases, your physician may have difficulty removing the tube and could face issues that make it more complicated, taking it beyond the E/M code. For instance, if the physician is unable to remove the PEG tube percutaneously with the usual amount of traction, they may cut the tube close to the stomach and perform a diagnostic endoscopy to determine the problem and retrieve the tube remnant. They could then place the replacement PEG tube percutaneously.

In this situation, you should report the endoscopy with 43247 (Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)) for the removal/ replacement of the PEG tube. More importantly, make sure the physician states in the progress notes the medical necessity of performing the endoscopy because the National Correct Coding Initiative (NCCI) edits state that intubating the GI tract includes subsequent removal of the tube, and you want to ensure you can document why you had to go above and beyond the standard procedure. Placement of the new gastrostomy would be reported with 43246-59 (Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube; Distinct procedural service) since it did involve endoscopic guidance.