General Surgery Coding Alert

Watch for same-day procedures.

When your general surgeon needs to modify a gastrostomy (G) tube, do you have the tools to pick the right code? Making a blunder could cost your practice over $200.

Let our experts familiarize you with the code options, and show you when you can — and can’t — separately charge for G-tube manipulations.

Know the Placement Options

You might choose one of several codes if your surgeon performs the initial G-tube placement, depending on guidance and other prooptions.

If the surgeon places the tube endoscopically, you should assign 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube), according to Heather Copen, RHIT, CCS-P, financial advocate with Goshen Physicians in Goshen, Ind. This is often referred to as a percutaneous endoscopic gastrostomy (PEG) tube.

Look for guidance: If the surgeon inserts the gastrostomy tube under fluoroscopic guidance you should use 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) instead.

Code E/M for Removal

The simplest G- tube modification your surgeon might perform is to remove the tube. Typically, the surgeon performs the procedure during an office visit by simply applying traction to pull the tube out.

CPT^® doesn’t provide a separate code for G-tube removal. Instead, you should report only the appropriate E/M code for the visit that involved the tube removal, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …).

Complications change code choice: Sometimes the surgeon might not be able to remove the gastrostomy tube with usual traction application. When that’s the case, your surgeon might opt to cut the visible portion of the tube as close as possible to the stomach and then perform an upper esophagogastroduodenoscopy (EGD) procedure to remove the remaining bit. There’s no separate charge for cutting the tube, but you can report the endoscopic removal of the remaining G-tube as 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body).

Choose Correct Reinsertion/Replacement Code

Several circumstances might result in your surgeon removing an existing gastrostomy tube and reinserting a new one in the established tract. For instance, the tube may be clogged or dislodged or the tract may be infected.

If the surgeon reinserts the existing tube or inserts a new balloon gastrostomy tube through the established tract without fluoroscopic or endoscopic guidance, you should report 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance).

Consider guidance difference: If the surgeon uses a fluoroscopic aid to guide the G-tube change, instead of 43760, you’ll select 49450 (Replacement of gastrostomy or cecostomy [or other colonic] tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).

Find endoscopy code: If your surgeon performs a reinsertion or replacement of a gastrostomy tube using endoscopic guidance, you’ll notice that there is not a distinct CPT^® code for the service. “In these cases, you’ll have to report the same CPT^® code that you would use for the initial PEG tube placement: 43246,” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash.

If you erroneously think that the lack of a “replacement” PEG tube CPT^® code means you should use 43760 as the “closest” code for the service, you could cost your practice over $200 (national facility amount for 43246 = $255.17; national facility amount for 43760 = $48.65 [conversion factor 34.023]).  

Beware global period: If your surgeon places a gastrostomy tube and must replace the tube due to a complication during the global period, you’ll need to report the replacement code with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period).

For example: Your surgeon performs a 49440 G- tube placement, then sees the patient seven days later because the tube has broken and become dislodged. Since the percutaneous tract is not well established, the surgeon decides to perform an EGD to remove the old tube and replace it with another endoscopically guided gastrostomy tube.

Since there is no replacement code using endoscopic guidance, you’ll report the procedure with the placement code: 43246. Because the service occurs in the 10-day global period for 49440, you’ll need to report 43246 with modifier 78.

Search for Other G-Tube Procedures

Your surgeon might perform other procedures to evaluate or de-clog a previously placed gastrostomy tube. When your clinician performs these procedures, you have other codes that you can report, as follows:

• 49460 — Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report
• 49465 — Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report.

Note: These services include any fluoroscopic guidance used during the procedure; don’t separately report an imaging code.