Radiology Coding Alert

Radiology coders were delighted to find a new CPT Codes describing naso-gastric (NG) tube placement when the 2001 codes were announced late last year. Their satisfaction was soon deflated when they realized that no relative value units (RVUs) had been assigned to the code on the Medicare physician fee schedule.

Unfortunately, this is a case where radiologists finally got a code that was exactly what they were looking for but then were told theyd still not get paid for the service, says Charlene Finchum, CPC, coding supervisor for the department of radiological sciences at the University of Oklahoma Health Sciences Center in Oklahoma City. The new code, 43752 (naso- or oro-gastric tube placement, necessitating physicians skill), defines a radiologists involvement when called on to place a feeding tube. This is typically a nursing service performed on hospitalized patients, she explains. However, sometimes the nurse is not able to place the tube and a physician, such as an interventional radiologist, is called in to provide the service.

Because 43752 reflects these unusual circumstances and describes the service as requiring physician skill, radiologists and coders were stunned to learn no RVUs had been assigned. We are hoping that this will be rectified in 2002, Finchum says.

43752 Bundled Into E/M Service

HCFA spokeswoman Ellen Griffith Cohen says the AMAs Relative Value Update Committee (RUC), which makes recommendations about RVUs, proposed no RVUs for 43752. As a result, the new code was implemented with Medicare status code B, which indicates it is considered a bundled service and not separately payable. In this instance, HCFA regards the code as bundled into E/M services, she notes.

This policy has created some confusion among Radiology Coders , who have interpreted HCFAs stance to mean they should bill a feeding tube placement as an E/M service (i.e., assigning a subsequent hospital care code like 99231 instead of 43752). This is not correct, Cohen says. Practices would report an E/M code only if the physicians services met the requirements of the code, she says. They would have to document the care they provided as it relates to specific levels of E/M service for instance, taking a history, conducting an exam and considering various levels of medical decision-making. If these services are performed, the radiology practice can assign an E/M code and the tube placement is considered included in that service.

However, in most cases, placement of an NG tube does not encompass all these key elements. The interventional radiologist does not perform the separate, distinct and full E/M service and, therefore, cant justify reporting the code.

Coding Alternatives Should Be Avoided

Some coding professionals recommend other coding alternatives, such as assigning 44500 (introduction of long gastrointestinal tube [e.g., Miller-Abbott] [separate procedure]) with modifier -52 to indicate reduced services. This, too, would be inappropriate because CPT policy clearly states that if a CPT code accurately describing a service is available, only that code should be reported. In fact, in a parenthetical notation below the code description for 44500, the 2001 CPT manual states, for naso- or oro-gastric tube placement, use 43752.

Radiologists may receive some reimbursement for their services during feeding tube placement if conditions require they use guidance during the procedure, Finchum notes. Fluoroscopy is most commonly used and reported with 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71024 [e.g., cardiac fluoroscopy]). Unfortunately, coders note that although billable, this code is rarely paid as well.