Radiology Coding Alert

CPT 2008 is offering up some of the gastrostomy tube changes you've been hoping for -- but not all of them. Here's what's in store for your percutaneous jejunostomy claims, gastro-jejunostomy claims and more in 2008.

CPT 2008 deletes 43750 (Percutaneous placement of gastrostomy tube) and replaces it with three new codes that help radiologists more precisely describe insertion of gastrostomy (49440), duodenostomy or jejunostomy (49441), or cecostomy or other colonic (49442) tubes:

• 49440 -- Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

• 49441 -- Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

• 49442 -- Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.

Helpful addition: Interventional radiologists are performing an increasing number of percutaneous jejunostomies (49441), so CPT 2008 adding a specific code for this procedure is very helpful, says Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

For 2007 services, practices used either 43750 or 43999 (Unlisted procedure, stomach) for this procedure.

Include RS&I: All of the above insertions take place "under fluoroscopic guidance including contrast injection(s), image documentation and report," and you therefore would not report this service separately, 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.

Because fluoro is inherent in the new codes, CPT 2008 deletes 74350 (Percutaneous placement of gastrostomy tube, radiological supervision and interpretation), which you used in 2007 for fluoroscopic guidance for tube placement, Miller says.

If your practice or facility is like that of Marylin Brinkman, CPC, with Clarian Health in Indiana, you're far more likely to replace tubes than place them. Stay alert: CPT 2008 also introduces three new codes for gastrostomy tube replacement:

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

• 49451 -- Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

• 49452 -- Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.

Imaging included in replacements, too: As with insertion codes 49440-49442, replacement codes 49450-49452 include fluoroscopic guidance. To reflect this, the AMA has revised 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation) to remove reference to the gastrointestinal system, Miller says.

Note: In 2007, you used 43760 (Change of gastrostomy tube) for all G-tube changes, Miller says. In 2008, coders will use 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance) only to report G-tube changes without imaging guidance -- an unlikely scenario for radiology coders, she adds.

CPT 2008 also revises several codes so they mesh with the added codes. In 2008, Miller says, the 44300 descriptor will add the following italicized words to clarify that 44300 is not the proper code for a percutaneous jejunostomy: Placement, enterostomy or cecostomy, tube open (e.g., for feeding or decompression), with the note "For percutaneous placement of duodenostomy, jejunostomy, gastro-jejunostomy or cecostomy [or other colonic] tube including fluoroscopic imaging guidance, see 49441-49442."

Although these new specific codes are helpful, "what we needed was a code for the placement of a [gastro-jejunostomy] tube," Brinkman says.

While you won't have a single code for placement, CPT 2008 does add 49446 (Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).

A note with the code tells you that "for conversion to a gastro-jejunostomy tube at the time of initial gastrostomy tube placement, use 49446 in conjunction with 49440."

Previously, CPT Assistant (October 1996) stated that you should use 43761-(Repositioning of the gastric feeding tube, through the duodenum for enteric nutrition) "only when repositioning the gastric feeding tube after (not at the same session as) placement of the feeding tube. Any repositioning to reach the final site for enteric nutrition is included in the initial placement procedure and is not coded separately."

So when the physician advanced the tube into the jejunum during initial insertion, you could report only the G-tube insertion (43750).

But based on the new guidance, for 2008 you will be able to report both 49440 and 49446.