General Surgery Coding Alert

Question: Under an internal audit, we identified a claim for an in-office PEG tube removal by the surgeon that we billed as 43760. The auditor claimed that the documentation for a simple PEG tube removal did not support 43760. Is that correct, and if so, what should we do?Oregon Subscriber

Kentucky Subscriber

Answer: Your auditor is correct that a simple in-office removal of a Percutaneous Endoscopic Gastrostomy (PEG) tube does not warrant reporting 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance). Code 43760 describes changing the PEG tube, which means performing both a removal of the old tube and insertion of a new one. Your surgeon documented only a simple removal.

For an uncomplicated PEG tube removal performed in your office, you should report an outpatient E/M code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient … ). Remember, you can’t report even an E/M code if the removal visit is part the global-surgical postoperative period.

Since you already submitted the claim with 43760, you’ll have to contact the insurer to correct the claim and deal with any overpayment. The 2017 Medicare Physician Fee Schedule (MPFS) pays $498.85 for non-facility (office) 43760 service (13.90 RVUs, conversion factor 35.8887). The highest office E/M (99215) pays just $146.43. If your insurer has issued payment, you’ll need to resubmit the claim with the correction and refund the overpayment.

CMS takes a strict view of providers’ obligations to return all overpayments, and failing to do so can result in civil money penalties, fraud investigations or even exclusion from the program. Most Medicare contractors have pre-written forms that you can fill out with the details of an overpayment. For instance, Part B MAC CGS Medicare has an “Overpayment Refund Form” on its website that you should complete and submit with refund checks so the insurer’s staff members know where to apply the payment.

If your insurer doesn’t offer such a form, you should send back the overpayment with a short letter that includes the patient’s name, claim number, ID number, the document control number of the processed claim, the reason for the refund, and the amount that you’re reimbursing.