General Surgery Coding Alert

Can't find a code for PEG tube removal? Here's why

Placement is only part of the story for percutaneous endoscopic gastrostomy (PEG) tube. Surgeons can also remove or replace all or a portion of such devices, and these procedures require unique coding solutions.
 
Here are three common coding problems with the advice you need to master them.

1. Select 43760 for Percutaneous Tube Replacement

If the surgeon replaces the PEG tube because of clogging or other factors, you should report 43760 (Change of gastrostomy tube), says Linda Martien, CPC, CPC-H, coding, documentation and compliance specialist for National Healing Corp. in Mexico, Mo. If the surgeon provides radiological supervision and interpretation for this procedure, you may also separately report 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation), according to CPT guidelines.
 
Don't -overcode-: You should not report 43750 (Percutaneous placement of gastrostomy tube) for tube replacement only. Code 43750 includes creating a new tunnel for the tube, which replacement does not require.
 
Watch for endoscope use: Sometimes, the surgeon may encounter a problem replacing the tube percutaneously (for example, if the surgeon is unable to move the tube). In such cases, the surgeon may perform a diagnostic endoscopy to determine the problem and assist in the tube removal. The surgeon then places the replacement PEG tube percutaneously, without using the scope.
 
In this case, you should report the diagnostic endoscopy and 43760 separately. You should also be sure that the physician documents in the patient record the medical necessity of performing the endoscopy.

2. E/M Is the Only Solution for Tube Removal

You cannot report a separate code for simple PEG tube removal because CPT contains no such code. If the surgeon removes the tube only, you can report only an appropriate-level outpatient E/M code (99201-99215), says Kathleen Mueller, RN, CPC, CCS-P, a registered nurse and reimbursement and coding specialist in Lenzburg, Ill.
 
Caution: You should not report 43247 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with removal of foreign body) for PEG tube removal. Removing a PEG tube does not generally qualify as foreign-body removal.
 
Exception: You may report 43247 if the surgeon must perform a scope to retrieve a broken portion of a PEG tube that remains in the stomach, Mueller says.
 
If the surgeon must perform a diagnostic endoscopy to remove the tube (due to complications, for instance), you may report the appropriate endoscopic procedure code (43200 or 43235, in some cases). Once again, however, the physician should document the unusual circumstances that required the endoscope's use.

3. 52 Makes the Case for Bolster Replacement

If your surgeon documents replacement of a -mushroom basket,- you-ll likely have to access modifier 52 (Reduced services) in addition to 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube).
 
Explanation: A mushroom-shaped basket, or bolster, holds the PEG tube in place on the inside of the stomach wall. Sometimes this device needs to be replaced, which involves the surgeon using endoscopy to go back into the stomach.
 
The procedure basically includes a reduced version of PEG tube placement and is best described using 43246-52. Be sure that you include documentation with your claim explaining the -reduced- nature of the placement.