ED Coding and Reimbursement Alert

You need a different code for radiologic supervision If a patient's gastrostomy tube (G tube) suddenly malfunctions, he will likely be unable to get the liquids, nutrients or medications that he needs, creating an emergency. For this reason, many patients with malfunctioning G tubes end up in the ED for treatment.
 
Who needs them? -G tubes are necessary for patients who need enteric nutrition, or any patient unable to have any oral intake for a prolonged period of time,- says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers.
 
Physicians may also administer medications through G tubes, says Elijah Berg, MD, FACEP, chief operating officer of Medical Reimbursement Systems Inc., an ED billing company in Stoneham, Mass. Don't Let Problems Clog Reimbursement According to Pfaff, when the liquid (IV fluid, medication, enteric nutrition, etc.) passes through the G tube, it can clog, kink, dislodge or malposition the tube, creating the need for a replacement.
 
For proper G tube replacement claims, the coder must be ready to check the physician's notes:
 
- for evidence of separate E/M services the ED physician might provide along with the G tube service.
 
- to see if the physician used contrast monitoring during the procedure.

- for evidence of radiologic supervision and interpretation during the procedure. Only then can a coder choose the right G tube code combination for the claim. Read on for a primer on selecting spot-on codes for your G tube services. Separate E/M From Tube Procedure When the encounter occurs in the ED, G tube replacements nearly always involve a separate E/M, Berg says.

-When a patient comes to an ED, it is the physician's legal and ethical obligation to evaluate the patient for the presence or absence of an emergency medical condition,- he says.
 
According to Berg, patients with displaced or non-functioning G tubes should have their hydration status and living situation evaluated. Further, the physician should assess the appropriateness of the patient's current care and check if the patient missed any doses of medications.
 
-There is no cookbook answer as to what (E/M) level this could be,- Berg says. -But if concern warrants labs to be drawn, or there is coordination of care with another physician, the service might warrant assignment of 99284.-
 
For example: A patient with a displaced G tube and evidence of dehydration comes to the ED from a nursing home. The emergency physician performs a detailed history and physical exam and orders labs, as well as IV fluids for rehydration. Examination of the tube shows a significant clog.
 
The physician reviews the lab tests, rehydrates the patient and changes the G tube before discharging him  back to the nursing home.
 
On the claim, you should:

- report 43760 (Change of gastrostomy tube) for the tube [...]