Otolaryngology Coding Alert

Your gastrostomy tube coding just got much clearer thanks to CPT 2008. Make sure your placement codes get the update they need with this take-away advice.

You won't have to educate staff on bread-and-butter otolaryngology surgery code changes this winter. "CPT 2008 doesn't contain any significant changes to the traditional ENT code set," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City.

But otolaryngologists who place gastrostomy tubes "will need to update fee sheets and be sure they use the right codes," 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 (UWP) and Children's University Medical Group (CUMG) Compliance Program.

If your otolaryngologist places a true percutaneous endoscopic gastrostomy (PEG) tube, 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) should be your code of choice for now and into the next year. CPT 2008 makes no changes to this code.

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. Generally, the tube's purpose is either to provide nutrition (a feeding tube) or to act as a drain (in place of a nasogastric tube).

When the physician places a gastrostomy tube percutaneously without using an endoscope, get ready to change your coding. You should now select 43750 (Percutaneous placement of gastrostomy tube). CPT 2008 deletes this code.

New way: Starting Jan. 1, you-ll instead code percutaneous gastrostomy tube placement with 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).

Guidance provides a clue: During this 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.

During this procedure, the surgeon punctures the abdominal wall from outside the body and inserts a wire, which she pulls up through the mouth. She then attaches the tube and pulls it back through the mouth to the opening in the stomach. The surgeon does not use the endoscope but will usually use either ultrasound or fluoroscopy to help guide her.

Code 49440 puts an end to separately reporting this ultrasound or fluoroscopic guidance. You can now report this ultrasound or fluoroscopic guidance separately from 43750 using 74350 (Percutaneous placement of gastrostomy tube, radiological supervision and interpretation), according to CPT guidelines--- if the surgeon handles the fluoroscopy and provides the interpretation. Otherwise, a radiologist will probably report 74350 independent of the surgeon.

But this added coding opportunity goes away in 2008. "Code 49440 will include all of the components to place the tube," Bucknam says. So you-ll use one code for the procedure and the associated imaging procedures.

If using a code in the stomach subsection of the digestive system seems like foreign CPT territory to you, relax. Because gastrostomy tubes are typically not about the stomach, CPT 2008 moves the g-tube percutaneous placement code to the abdomen subsection.

Surgeons usually place gastrostomy tubes to bypass the esophagus, to increase feedings or to decompress the intestines. "Moving the [gastrostomy tube placement] code to the general abdominal section makes sense in that context," Bucknam says.

You-ll have clarification on g-tube replacement code 43760 (Change of gastrostomy tube). CPT 2008 adds "percutaneous, without imaging or endoscopic guidance" to the code's descriptor. The language makes the code's appropriate use more clear, Bucknam says.

CPT 2008 also introduces several new codes for gastrostomy tube maintenance. "A surgeon might use these codes if the tubes weren't placed endoscopically," says Kathleen A. Mueller, RN, CPC, CCS-P, CMSCS, a healthcare consultant in Lenzburg, Ill.

Keep your eye open to documentation supporting:

- 49450 -- Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

- 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

- 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.