Radiology Coding Alert

Even the most experienced radiology coders find reporting gastrostomy tube placement confusing. The pro-cedures are complex, and different coding options apply in different situations. According to Jeff Fulkerson, supervisor of radiology billing at the Emory Clinic in Decatur, Ga., Coders must understand what is being done and match the appropriate codes to the procedure.

Percutaneous gastrostomy tubes (G-tubes) are placed by an interventional radiologist to provide nutritional support to patients who have difficulty eating or swallowing, explains Elizabeth Kaese, CPC, coding specialist with Medi-Data Services Ltd., which provides billing and consulting services to radiology, gastroenterology, radiation oncology and cardiology practices in the Chicago area. The gastric tube is positioned directly in the stomach, while the gastrojejunal tube (GJ-tube) extends from the stomach into the jejunum, the portion of the small intestine between the duodenum and the ileum.

Both G- and GJ-tubes deliver liquid nutritional formulas directly into the digestive tract where they can be absorbed easily. Many GJ-tubes also have two lumens, Kaese adds, one that terminates in the jejunum and the other that terminates in the stomach. The G-tube or the gastric lumen of a GJ-tube also may be used to provide gastric drainage in cases of total or partial obstruction of the stomach.

Coding New G-tube and GJ-tube Placements

When a new gastric tube is placed, Fulkerson says, coders should report 43750 (percutaneous placement of gastronomy tube), according to conventions recommended by the Society for Cardiovascular and Interventional Radiology (SCVIR). 74350 (percutaneous placement of gastrostomy tube, radiological supervision and interpretation) also would be assigned.

If a new GJ-tube were being placed, coders may use one of two coding combinations:

43750 and 44373 (small intestinal endoscopy,
enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous
gastrostomy tube to percutaneous jejunostomy tube), or

43750 and 43761 (repositioning of the gastric
feeding tube, any method, through the duodenum for
enteric nutrition).

Either of these methods describes the procedure, which involves extending the reach of a gastrostomy tube by positioning the longer GJ-tube into the small intestine. While certain coding advisors recommend the first coding approach (43750 and 44373), the second combination (43750 and 43761) also may be used, according to Gary S. Dorfman, MD, FACR, FSCVIR, past president of SCVIR and president of Health Care Value Systems Inc. in North Kingstown, R.I., which provides practice management services as well as revenue enhancement techniques through coding and billing support.

The first coding approach has utility especially in cases in which an in-depth evaluation of the small bowel is performed during the tube placement procedure, he explains. Alternatively, if the second coding approach is used and an in-depth evaluation of the small bowel is also performed, the small bowel radiography code, 74251 (radiological examination, small bowel, includes multiple serial films; via enteroclysis tube), should be added.

According to the SCVIR, however, the second coding approach described above (43750 and 43761) has been subjected to an erroneous Correct Coding Initiative (CCI) edit in the Medicare program. Dorfman, who also serves as representative to the American Medical Associations CPT Advisory Board, reports that the SCVIR is taking action to protest what it describes as an ill-conceived and unfounded edit. The code carries a CCI modifier indicator of 1, thereby allowing the use of modifier -59 (distinct procedural service) if one can make the case that the two services are being performed in anatomically separate areas. Because the stomach and the jejunum are different anatomic areas, one theoretically could justify using this coding approach and appending modifier -59 to code 43761. Should the SCVIR be successful in reversing this CCI edit, one would not have to use modifier -59 with this coding approach.

Coders should also be aware that some experts recommend against reporting 43761 during the placement of a new GJ-tube. They cite an article in the October 1996 CPT Assistant that states this code should be used only when repositioning the gastric feeding tube after it has been placed not during the same session. The article explains that any repositioning of a tube to reach the final site (i.e., the jejunum) is included in the initial placement procedure and is not coded separately.

In addition, many experts agree that interventional radiology coders should add 74355 (percutaneous placement of enteroclysis tube, radiological supervision and interpretation). Coders also would add 74350 if the procedure involved a dual lumen (two openings in the GJ-tube), Fulkerson points out. This latter supervision and interpretation (S&I) code, however, should be used only if there is radiographic confirmation of the intra-gastric location of the second lumen opening.

If the interventionalist uses ultrasound guidance during the abdominal needle puncture in the placement of a new G-tube or GJ-tube, coders would add 76942 (ultrasonic guidance for needle biopsy, radiological supervision and interpretation) to either of the above scenarios.

Conversion of G-tube to GJ-tube

In some instance, Fulkerson notes, an interventionalist will need to convert an indwelling G-tube to a GJ-tube on a date of service other than the date the G-tube was placed. This is different than placing a new GJ-tube as described earlier, he says. The interventionalist or some other physician will have previously placed the G-tube, and that procedure would have been coded, billed and reimbursed. Now, to further augment the patients feeding, the radiologist may decide a GJ-tube is more appropriate. He or she will therefore need to remove the G-tube and convert it to a GJ-tube.

This procedure would be assigned code 43761, along with the S&I code 74355. As before, 74350 may be added for a dual-lumen tube if radiographic confirmation of the intra-gastric location of the second lumen opening is performed.

Editors Note: Code 43750 is used to report the initial G-tube placement and carries a 10-day global period. Therefore, if the conversion to a GJ-tube is required because of complications during those 10 days, coders would need to append modifier -78 (return to the operating room for a related procedure during the postoperative period) to code 43761.

Changing G-tubes and Managing Dislodged G-tubes

Occasionally an indwelling G-tube will need to be replaced. Coding for a G-tube change-out is 43760* (change of gastrostomy tube), along with radiology code 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g., gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation).

These codes would be assigned if the G-tube had become dislodged and needed revision. These codes, however, would be reported only if the tract between the abdominal wall and the gastric lumen remained patent and easily accessible without the performance of a sinogram and tract renegotiation, Dorfman says.

If the tract is not negotiable and the procedure also entails the performance of contrast injection into the tract with subsequent guidewire manipulation, the sinogram code should be added to its S&I code (20501*, injection of sinus tract; diagnostic [sinogram]; and 76080, radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation). The G-tube placement code 43750 with modifier -52 (reduced services) would then be used with the change of catheter S&I code 75984.

Change GJ-tubes and Manage Dislodged GJ-tubes

When a GJ-tube is changed, the interventionalist repositions the gastric and jejunal ports over a guidewire. Coding for this procedure is 43761. The S&I code 75984 would be assigned, along with 74350 if there was a dual lumen (assuming there was appropriate radiographic confirmation as previously noted).

Interventionalists also may replace a GJ-tube that has become dislodged. Fulkerson notes that coding will depend on whether the replacement was simple (i.e., the track has remained open) or complex (if the track is closed, whereby a sinogram with fluoroscopy is required to renegotiate it and the track needs to be redilated).

For a simple GJ-tube replacement, coders would assign 43761 and 75984, with 74350 added for dual lumen.

In the case of a complex replacement, Dorfman notes that one coding method used by some experts is 44373, 74355 and 43750-52. Again, 74350 may be added for dual-lumen catheters if the appropriate radiographic service is provided. Modifier -52 is assigned to 43750 to indicate that the placement is not for a new tube.

Dorfman notes, Analogous to the previous discussions regarding the placement of a new GJ-tube and the complex replacement of a dislodged G-tube, 43761 may also be used instead of but not in addition to 44373. If a sinogram were performed in addition to the tract renegotiation, it would be coded with 20501 and 76080. Therefore, in this coding scenario, coders would report 20501, 43761 and 43750-52 in conjunction with the S&I codes 76080 and 74355 (with 74350 if appropriate).

Dorfman adds that the concerns about CCI edits and the use of modifier -59 apply in this case as well, since coders would be using 43750 (with modifier -52) in conjunction with 43761 (with modifier -59 as long as the CCI edit remains in place).

Patency Check of G- and GJ-tubes

At times, the interventionalist may be requested to inspect an indwelling tube to check for leakage, confirm that it is in the correct position or ensure patency. In these situations radiology code 76080 typically would be assigned, Fulkerson says.

In some instances, the radiologist also may assign 20501 or 49424 (contrast injection for assessment of abscess or cyst via previously placed catheter [separate procedure]) to report the surgical component of the injection of contrast, he adds. If the injection is performed via the indwelling G- or GJ-tube, the 49424 code would be correct. Code 20501 most appropriately should be reserved for injections of the tract in the case of dislodged tubes.

An easy-to-use chart,Coding Strategies for G-tube and GJ-tube Procedures has been inserted in this issue to facilitate your G- and GJ-tube billing.