General Surgery Coding Alert

Find out if you must use different procedure codes.

When two surgeons band together for a percutaneous endoscopic gastrostomy (PEG) tube procedure — one to determine the gastrostomy site using an upper gastrointestinal duodenoscopy, and the other to make the abdominal wall incision and place the PEG tube — do you know how to code?

Challenge: Check out our expert advice for code and modifier choices to ensure each surgeon receives appropriate pay for his work in multiple-surgeon PEG tube coding.

Focus on Single Procedure

Here’s the scenario: Under sedation, surgeon A uses a flexible endoscope to perform an upper gastrointestinal duodenoscopy to determine the site where a gastrostomy tube can be inserted.

Another surgeon places the gastrostomy tube through an incision made in the abdominal wall using the reference of the location determined by the endoscopic procedure. The gastrostomy tube is held in place by a retention disk placed along the anterior abdominal wall.

Code it: Since work done by both surgeons is part of the same procedure, you should use the same CPT^® code for reporting the services provided by both of them.

When the physician places the PEG tube endoscopically, then you should assign code 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube),according toHeather Copen, RHIT, CCS-P,financial advocate with Goshen Physicians, Goshen, Indiana.

Warning: Don’t make the mistake of coding the endoscopic part of the procedure using 43246 and the surgical part using 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report), because both the endoscopy and the abdominal puncture procedures in this case are part of a single procedure, not two distinct procedures.

More evidence: Note that 49440 entails fluoroscopic guidance, which isn’t documented in the case example. Additionally, Correct Coding Initiative (CCI) edits do not allow you to report 49440 and 43246 together under any circumstances.

Use modifier 62: “If two [surgeons] are required to perform the PEG insertion, you may append a modifier depending on the role of each surgeon,” says Linh Nguyen, CPC, medical coder witha practice in Evansville, Indiana. You will need to append the modifier 62 (Two surgeons) to both the claims to help the payer identify that there were two physicians involved in performing the same procedure on the patient. “You can only assign this modifier if both are working as primary surgeons and performing distinct/separate parts of the same procedure,” reminds Nguyen.

“Typically with co-surgery, each surgeon will dictate his/her specific part of the procedure separately, so documentation is very important to assigning the correct modifier,” says Copen. Each of the surgeons will receive 62.5 percent of the Medicare Physician Fee Schedule Database fee indicated for the procedure.

Reminder: The rules about when you can and can’t use modifier 62 may vary by state, so be sure to check your state regulations and your individual payers to see if modifier 62 is right for your practice.

Know When to Use Modifier 80 Instead

In most instances when two surgeons perform a gastrostomy tube placement, one will handle the endoscopic procedural part and the other will perform the surgical part of the procedure. In some circumstances, you will find that one of your surgeons performs the entire procedure while the other assists in prep and treatment of the incision into the abdomen.

In such a scenario, you should avoid using modifier 62 with 43246. Instead, you should report the primary surgeon’s work with 43246 and the assisting surgeon’s work using 43246 with the modifier 80 (Assistant surgeon).

“It is important to know the difference between co-surgeon and assistant surgeon because reimbursement is different,”says Copen. When you use modifier 80, the primary surgeon will receive 100 percent of the Medicare Physician Fee Schedule Database fee indicated for the procedure, while the assisting surgeon will receive only16 percent of the scheduled fee for the procedure.

Warning: Some Medicare carriers and private payers may specify that you must code dual-physician PEG tube placement by indicating one physician as the assistant. “For Medicare, 43246 has a modifier 80 payment policy indicator of 0 (Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity),” says Nguyen. Be sure to check your state rules and payer policies to determine which of the modifiers (62 or 80) you should use when two surgeons perform a PEG tube placement.