Medicare Compliance & Reimbursement

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.

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.

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.

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 replacing the tube percutaneously (for example, if he is unable to move the tube). In such cases, he may perform a diagnostic endoscopy to determine the problem and assist in the tube removal. He then places the replacement tube percutaneously without using the scope.

In this case, you should report the diagnostic endoscopy (43235) and the percutaneous tube replacement (43760) separately. Just be sure that the physician documents in the patient record the medical necessity for performing the endoscopy. But if the physician does use the endoscope to place the feeding tube, you should once again revert to 43246, according to CPT instructions. In this case, you would not report either 43760 or 43235.

When the physician replaces a gastrostomy tube under fluoroscopic guidance, select 49450 (Replacement of gastrostomy or cecostomy [or other colonic] tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report), Parks says. This procedure includes using contrast material, as well. Note that 49450 differs from 43760 because the latter describes replacement without fluoroscopic guidance.

Additional codes for gastrostomy tube maintenance include 49460 (Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy [or other colonic] tube, any method, under fluoroscopic guidance including contrast injection[s], if performed, image documentation and report) for mechanical removal of obstructive material by any method and 49465 (Contrast injection[s] for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy [or other colonic] tube, from a percutaneous approach including image documentation and report) to describe radiological evaluation of an existing gastrostomy tube via a percutaneous approach. Both 49460 and 49465 include fluoroscopic guidance, when performed.

When the physician converts a gastrostomy tube to a gastro-jejunostomy tube, report 49446 (Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report). The gastro-jejunostomy tube is a dual-lumen feeding tube. Typically, the surgeon uses the gastric lumen for decompression, while the jejunal lumen administers nutrition.

Like many gastrostomy procedures, 49446 includes fluoroscopic guidance, when used. You would not report any additional codes with 49446 for guidance, contrast injection(s), image documentation and report.

Initial placement calls for two-code combo: Although 49446, which CPT added for 2008, is helpful, "What we are missing is a code for the initial placement of a [gastro-jejunostomy] tube," says Marylin Brinkman, CPC, with Clarian Health in Indiana.

Although no single code exists to describe an initial G-J-tube placement, CPT does provide instructions: "For conversion to a gastro-jejunostomy tube at the time of initial gastrostomy tube placement, use 49446 in conjunction with 49440."