Radiology Coding Alert

Report components inappropriately, and you could face a $294 payback.

You've had nearly a year to adjust to CPT's GI tube codes, so now's your chance to be sure your tube claims are in tip-top shape. Read through these excerpts from three actual cases and see if you can choose the same codes as the experts.

Scenario excerpt: The stomach was inflated with air via the nasogastric tube. The stomach was punctured above the colon under fluoroscopic guidance. The tract was serially dilated and a gastrostomy tube was placed utilizing pull technique. The balloon was inflated and intragastric placement was confirmed with contrast injection. The wound was dressed.

Solution: You have an all-in-one code you can use for this procedure: 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).

During this percutaneous procedure, the radiologist punctures the abdominal wall from outside the body and inserts a device under fluoroscopic or ultrasound guidance. This allows the radiologist to pull the stomach up to the abdominal wall and then insert the tube percutaneously without using an endoscope.

Key: Fight the temptation to report components separately. For example, one practice asked if they should report 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) and 76080 (Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation) with 49440 for the above scenario.

The answer is no. This note doesn't support reporting an endoscopy code, and 49440 includes all of the components described in this note, 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.

Based on 2009 relative value units, if you did report 43246 in a facility setting and 76080-26 (Professional component) you'd be risking getting roughly $294 extra for this claim from Medicare -- an amount auditors would want back.

Tip: The doctor places the gastrostomy tube, or G-tube, into the stomach for long-term food, fluid, and medication administration. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube.

Scenario excerpt: The J-tube was unclogged under fluoro guidance. Intrajejunal and intragastric placement were confirmed with contrast injection. The catheter was flushed. The catheter is ready for immediate use.

Solution: For this case, you should 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).

The scenario specifies a J-tube (jejunostomy tube), which runs either into the jejunum (part of the intestine a short way after the stomach) or into the stomach and then into the jejunum.

But don't miss that you can report 49460 for mechanical obstruction removal from any of the following:

• gastrostomy tube

• duodenostomy tube

• jejunostomy tube

• gastro-jejunostomy tube

• cecostomy tube

• other colonic tube.

Note that this code, like 49440, includes fluoroscopic guidance, so you should not report fluoro separately, says Cheryle Mappa, CPC, physician-based coder with Loyola University Physician Foundation in Westchester, Ill.

Scenario excerpt: An 18-gauge needle was advanced into the cecum under fluoroscopic guidance. A wire was coiled into the colon. The tract was dilated and an 18 French pigtail catheter was placed just below the expected location of the fistula to the wound. The catheter was secured and sterilely dressed.

Solution: For this report, look to 49442 (Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report).

Tip: A cecostomy tube, or C-tube, is a tube inserted into the cecum, which is the first part of the large bowel, says Clinesta Williams, business office assistant director with Advanced Diagnostics Healthcare in Houston.

Patients or caregivers can use the cecostomy to administer a small-volume phosphate enema followed by a saline enema to quickly and completely evacuate and cleanse the large intestine, emptying through the anal opening.