General Surgery Coding Alert

Without a careful reading of the op note, you-re probably coding incorrectly Not all gastrostomy placements are endoscopic, and CPT actually contains four codes for procedures of this type. In addition, if your surgeon performs other procedures at the same time, you may not be able to code for the gastrostomy placement at all. True PEG Calls for 43246 If your surgeon places a true percutaneous endoscopic gastrostomy (PEG) tube, 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) should be your code of choice.
 
What to look for: The operative note for 43246 will describe an upper GI endoscopy with insertion of the gastrostomy tube. As the code descriptor specifies, placement of this type involves both an endoscopic and a percutaneous (through the skin) component.

-Surgeons will usually place a tube of this type without performing any other abdominal procedures,- says Joshua T. Rubin, MD, of the department of surgery, Division of Surgical Oncology at the University of Pittsburgh. Generally, the purpose of the tube is either to provide nutrition (a feeding tube) or to act as a drain (in place of a nasogastric tube), Rubin says. Percutaneous-Only Means 43750 When the physician places a gastrostomy tube percutaneously, without an endoscopic component, select code 43750 (Percutaneous placement of gastrostomy tube).
 
Guidance provides a clue: During this procedure, the surgeon punctures the abdominal wall from outside the body and inserts a device under fluoroscopic or ultrasound guidance. This allows the surgeon to pull the stomach up to the abdominal wall. The surgeon then inserts the tube percutaneously without using an endoscope, Rubin says.
 

During this procedure, the surgeon punctures the abdominal wall from outside the body and inserts a wire, which she pulls up through the mouth. She then attaches the tube and pulls it back through the mouth to the opening in the stomach. The surgeon does not use the endoscope but will usually use either ultrasound or fluoroscopy to help guide her, Rubin says.
 
Tip: You can report this ultrasound or fluoroscopic guidance separately from 43750 using 74350 (... radiological supervision and interpretation), according to CPT guidelines -- if the surgeon handles the fluoroscopy and provides the interpretation. Otherwise, a radiologist will probably report 74350 independent of the surgeon.
 

You Can Report Multiple Endoscopies If the surgeon performs another endoscopic procedure (for instance, 43239, Esophagogastro-duodenoscopy [EGD] with biopsy) during the same session as PEG tube placement (43246), you can bill for both procedures separately. Keep in mind, however, that the -multiple-endoscopy- [...]