Internal Medicine Coding Alert

Find out why 43247 just won't do you any good.

If you've asked yourself frequently what CPT® code to use when a physician removes a percutaneous endoscopic gastrostomy (PEG) tube, and haven't found the answer, it's time you set your sights on reporting an E/M service.

Fact: You wouldn't code a non-incisional PEG removal done in an office setting because CPT® bundles PEG tube removal into the E/M, according to CPT® Assistant. Instead, you would report the procedure with the appropriate E/M code for that visit.

E/M Remains Your Best -- and Only -- Selection

Suppose your GI surgeon only removes the PEG tube and performs no other procedure. In this case, you can report an outpatient E/M code (99201-99215).

You can use 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance) linked with diagnosis code V55.1 (Attention to gastrostomy) if the gastroenterologist removed the PEG tube then placed another one (replacement). For instance, a GI surgeon replaced a patient's PEG tube because of clogging, then you should bill 43760, says Linda Martien, CPC, CPC-H, coding, documentation and compliance specialist for National Healing Corp. in Mexico, Mo. Replacing an endoscopically inserted G-tube can either go smoothly or it can be more involved.

Example: While replacing the tube percutaneously, the surgeon could not remove the tube with the usual amount of traction. She decides to cut the tube close to the stomach and performs a diagnostic endoscopy to determine the problem and retrieve the tube remnant. After doing this, the surgeon places the replacement PEG tube percutaneously, without using the scope. In this case, you should report the endoscopy as 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body) for the removal/replacement of a PEG tube. More importantly, make sure the physician states in his notes the medical necessity of performing the endoscopy because in Chapter VI: Digestive system of the Correct Coding Initiative (CCI) edits, it states: "Intubation of the GI tract (e.g., percutaneous placement of g-tube) includes subsequent removal of the tube. CPT® codes such as 43247 should not be reported for routine removal of previously placed therapeutic devices."

Option: If the surgeon provides radiological supervision and interpretation for this procedure, you may also separately report 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation).

Others would use 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) to report the tube placement after retrieval of the broken remnant, which is an incorrect option. Remember, 43246 includes creating a new tunnel for the tube, which replacement does not require.