Medicare Compliance & Reimbursement

Hint:G-tube procedures now include fluoroscopic guidance, when used Recent AMA revisions have made reporting gastrostomy tube procedures much clearer, but coders familiar with G-tube coding prior to CPT 2008 will have to unlearn old habits. Follow these five tips to re-educate yourself now and avoid trouble later. 1. Stick With 43246 For True PEG If your physician places a true percutaneous endoscopic gastrostomy (PEG) tube, you should continue to select 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube). "There's only one acceptable way to code a PEG placement: using 43246," says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. What to look for: The operative note for 43246 will describe an upper GI endoscopy with gastrostomy tube insertion. As the code descriptor specifies, placement of this type involves both an endoscopic and a percutaneous (through the skin) component. Specifically, using an endoscope to visualize and guide her, the surgeon inserts a hollow needle percutaneously through the abdominal wall into the lumen of the stomach. The surgeon then threads a thin wire through the needle into the stomach and, using the endoscope, grips the wire and pulls it up and out of the mouth. The surgeon then attaches the G-tube to the end of the wire. By withdrawing the wire back down the esophagus and out of the abdominal incision, the surgeon guides the G-tube into place. 2. Scope-Free Placement Calls For 49440 If your surgeon places a gastrostomy tube percutaneously without using an endoscope, you should select 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) rather than 43246. Guidance provides a clue: During this percutaneous procedure, the surgeon punctures the abdominal wall from outside the body and inserts a device under fluoroscopic or ultrasound guidance. This allows the surgeon to pull the stomach up to the abdominal wall and then insert the tube percutaneously without using an endoscope. Include supervision and interpretation: "Code 49440 will include all of the components to place the tube," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. As a result, you cannot code separately for fluoroscopic imaging with percutaneous gastrostomy tube placement. 3. Select 43760 For Percutaneous Replacement You should report 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance) if the surgeon replaces a PEG tube because of clogging or other factors. This code does not include imaging guidance (see tip 4 for replacement with guidance). Watch for endoscope use: Sometimes, the physician may have a problem [...]