Part B Insider (Multispecialty) Coding Alert

Hint: Append modifiers when two specialists are carrying out the procedure.

When your gastroenterologist performs a gastrostomy to place a gastrostomy tube, look for guidance used to perform the procedure and the number of clinicians involved to arrive at the accurate CPT^® code.

Check Use of Endoscope for Tube Placements

Your gastroenterologist will often use aids such as endoscopy or fluoroscopy to help position the gastrostomy tube. If your clinician is performing an upper endoscopy prior to determine the location of the incision to place the gastrostomy tube, you’ll need to report the procedure that your gastroenterologist performed using 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube).

Caveat: When your gastroenterologist uses endoscopy as an aid for the placement of the gastrostomy tube, you’ll not report the actual placement of the gastrostomy tube separately using another CPT^® code as the descriptor for 43246 includes the placement of the gastrostomy tube also.

Use Multiple Endoscopic Rule for Multiple Procedures

You’ll need to be aware of what you need to report when your gastroenterologist performs other endoscopic procedures in the same session in which he introduces a PEG tube. “If your gastroenterologist performs an EGD/PEG tube placement, and in the same session performs another endoscopic procedure such as EGD/bx, the first thing to do is check the NCCI edits for bundling issues,” says Bridgette Martin, LPN, CPC, CGIC, Coding Specialist - Digestive Care Center, Evansville, Indiana.

 “Multiple endoscopy rules do apply, so expect reductions on the second procedure,” reminds Martin. The procedure which has a higher RVU (relative value units) will get paid at 100 percent and the other procedure will get paid by deducting the amount paid out for the basic endoscopic procedure from its standard fee schedule amount.

Coding example: Your gastroenterologist performs a directed percutaneous endoscopic tube placement for a patient who is unable to take food orally. Under sedation, your gastroenterologist performs an upper EGD to determine the site in which the gastrostomy tube can be inserted.

Using the aid of the endoscope, your gastroenterologist determines the site for incision and places the gastrostomy tube. The gastrostomy tube is held in place by a retention disk placed along the anterior abdominal wall.

During the procedure, your gastroenterologist notices two suspicious lesions in the esophagus and decides to perform biopsies to determine the nature of the lesions.

What to report: In the coding scenario mentioned above, your gastroenterologist performed two endoscopic procedures, namely, endoscopy with biopsy and endoscopy with directed percutaneous endoscopic gastrostomy tube placement. You’ll report 43246 for the endoscopic tube placement in the first line of the1500 form, as this has a higher RVU value and it will be paid at 100 percent. You’ll report the biopsy with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) and this will be paid out by deducting the value of the base endoscopy procedure from its standard scheduled fee.

More Than One Physician? Check Before Appending Mod 62 for PEG Tube Work

When two specialists are performing a PEG tube placement with one of your gastroenterologists performing the endoscopic part of the procedure and the other performing the incision and placement of the gastrostomy tube, you cannot report two different CPT^® codes for the services provided by the two clinicians by splitting the procedures.

Instead, you’ll have to report the services of both physicians by reporting the same CPT^® code separately for each of them. So, you’ll report 43246 for a directed endoscopic tube placement performed by two gastroenterologists.

However, you’ll have to append the modifier 62 (Two surgeons) to both of the claims in order to help the payer know that there were two specialists performing the procedure. “Both physicians will need to report 43246 with a modifier 62 which signifies that there were two surgeons,” says Heather Copen, RHIT, CCS-P, Program Chair-Health Information Technology at Ivy Tech Community College-Northeast, Fort Wayne, Indiana. “Without the modifier 62 the insurance company may deny one or both of the physician’s claims stating that it is a duplicate claim.” Each of the gastroenterologists will receive 62.5 percent of the Medicare Physician Fee Schedule Database fee indicated for the procedure.

To use modifier 62, each surgeon must perform a distinct part of one procedure and must account for that operative work by appending modifier 62 to the code that best represents the service provided. “It is also important that each physician clearly document his/her part in the procedure as this can be used to justify the need for two surgeons if the claim is denied,” reminds Copen.

Reminder: The rules about when you can and can’t use modifier 62 may vary by state, so be sure to check your state regulations and your individual payers to see if modifier 62 is right for your practice.

Apply 49440 For Fluoroscopic Aids

If instead of using endoscopy to direct the placement of the gastrostomy tube, your clinician uses other aids such as fluoroscopy to place the tube, you cannot report the procedure using 43246. Instead, you’ll have to report such a placement using 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report). Based on guidance used for the procedure, your reporting for the procedure will change. Since fluoroscopic guidance was used instead of endoscopy, you will have to use 49440 and not 43246.

Coding example: Your gastroenterologist decides to place a gastrostomy tube for a patient with feeding difficulties. He initially insufflates the abdomen using air passed through an orogastric tube. He then makes an incision in the abdomen wall using fluoroscopic aid for the placement of the gastrostomy tube. He then passes a large needle and suture material that is attached to the orogastric tube and then pulled up. The gastrostomy tube is attached to the suture material and then passed into the stomach and through the incision and sutured in place. Tube placement is confirmed using fluoroscopic aids. You’ll report the entire procedure that your gastroenterologist performed using 49440.