General Surgery Coding Alert

Question: An established patient comes to the office complaining of rectal bleeding. The doctor performs -gastric aspiration,- noting no blood. How should I report this case?


Michigan Subscriber

Answer: Report 91105 (Gastric intubation, and aspiration or lavage for treatment [e.g., for ingested poisons]).

Previously, you could have used 43752 (Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance [includes fluoroscopy, image documentation, and report]), but this code now includes fluoroscopic guidance.

Physicians perform gastric lavage procedures to find out whether a patient has active bleeding from the stomach, and the physician may place the tube either orally or nasally. In a case like this, she would probably insert the tube through the nose.

Make sure there is proper documentation and a procedure note to reflect the medical necessity for the physician's involvement.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, charge capture manager for the University of Washington Physicians.