Pediatric Coding Alert

Question: When the nurse performs a gastrostomy tube change in our office we bill a CPT 99211 . However, the insurance company wont pay for this service. They say its included in the 99211. How can we solve this problem?

Anonymous IL Subscriber

Note: The example of getting paid for gastro tube removal and an E/M visit is merely one instance of this problem. The answer below can be used when coding for other procedures preformed with an E/M service as well.

Answer: The solution is to bill only the tube change, which is 43760* (change of gastronomy tube). Most insurance companies wont pay for both the nurse visit and the tube change, and since 43760* pays $142 to $173, according to HealthCare Consultants 1999 Physicians Fee & Coding Guide, you would definitely rather be reimbursed for 43760* instead of 99211 (which pays $27 -$37). Pediatric gastroenterologists, if they are doing a tube change the same day that they do a consultation, need to use a different diagnosis code for the consultation in order to get paid for their visit.

Here is the general theory: The 99211 can be billed with the 43760* if the nurse provides some significant care or patient evaluation in addition to the tube change, and documents this care. Does the nurse take a temperature and weight, evaluate the childs complexion and responsiveness, observe the tube entry site for possible infection, irritation, or open wound? Is it medically necessary that the nurse evaluate the patient prior to changing the tube, as documented by the physician? If so, then you have support for billing the 99211 in addition to the 43760. But there are three rules to follow.

1. Remember to attach modifier -25 (significant, separately identifiable E/M service) onto the 99211.

2. Use separate diagnosis codes (while not strictly necessary, separate diagnosis code for each CPT code are often helpful). Here are some suggested codes to use in addition to the problem requiring a gastric tube: If the gastric tube enters through an artificial opening use V55.1 (attention to artificial openings); if the child is a newborn, V29.0 (observation and evaluation of newborns and infants for suspected condition not found; observation for suspected infectious condition) or V29.8 (observation and evaluation of newborns and infants for suspected condition not found; observation for other specified suspected condition); if the child is older, V71.8 (observation and evaluation for suspected conditions not found; observation for other specified suspected conditions).

3. Be prepared to appeal every denial. You must be able to demonstrate documentation separate from the note for the tube change, showing significant medical effort by the nurse which is medically necessary as directed by the physician.

Note that 43760* is a starred procedure, which
theoretically means you can bill the E/M services codes, even without the modifier.

The bottom line: For a general pediatrician, simply billing for the gastric tube change is the best answer. For the pediatric gastroenterologist, this procedure occurs often enough that it may be worth the battle to convince insurers to pay for both.