ED Coding and Reimbursement Alert

Question: A patient with complaints of stomach pain and rectal bleeding reports to the ED. The doctor performed a gastric aspiration on the patient. What code best represents this procedure?


Mississippi Subscriber


Answer: The ED often has to perform gastric aspiration/lavage procedures on patients to discover if the patient is bleeding from the stomach. Your code choice depends on whether or not your doctor used fluoroscopic guidance during the encounter. If the physician does not use fluoroscopic guidance during the aspiration:

- report 91105 (Gastric intubation, and aspiration or lavage for treatment [e.g., for ingested poisons]) for the encounter. 

- attach 569.3 (Hemorrhage of rectum and anus) to 91105 to represent the patient's bleeding.

- attach 536.8 (Dyspepsia and other specified disorders of function of stomach) to 91105 to represent the patient's stomach pain. But if the notes show that the physician used fluoroscopic guidance during the encounter:- report 43752 (Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance [includes fluoroscopy, image documentation and report]) for the encounter.

- attach 569.3 to 43752 to represent the patient's bleeding.

- attach 536.8 to 43752 to represent the patient's stomach pain.