ED Coding and Reimbursement Alert

Question: A 93-year-old patient presented to the ED from a nursing home with an indwelling catheter that needed to be replaced. His incision site was cleaned, the old catheter removed, and a new rubber catheter inserted. The patient was then taken to the x-ray department, where the tube was injected. However, the x-rays revealed that the tube was kinked, blocking the flow of the injection.
 
The tube was withdrawn under direct fluoroscopic guidance and replaced. The new tube demonstrated good flow of dye into the jejunum, and was therefore sutured in place. How should I code this?

Colorado Subscriber  
Answer: The first issue is whether an E/M was performed, says Michael A. Granovsky, MD, director of coding and reimbursement for Greater Washington Emergency Physicians, an emergency physician group based outside Washington, D.C.
 
"The whole chart would have to be evaluated to see if an E/M would apply," he says. "Was the patient evaluated for dehydration? Was the patient evaluated for abdominal pain? It is likely that some level of E/M would apply in this case. Good clinical standards would dictate that we don't just walk in the room and put in a new gastrostomy/jejunostomy tube."
 
The next issue is whether the tube change represents a separately identifiable procedure from the E/M. The replacement of the tube can be reported with 43760 (change of gastrostomy tube), although Granovsky notes that some Medicare carriers have been inconsistent about reimbursing this code when the change was performed in nursing homes and other outpatient settings.
 
The final issue, according to Granovsky, is whether the fluoroscopic monitoring qualifies as a procedure separate from the tube change. "There is clearly an indication for fluoroscopic guidance here, with the procedure documenting the result. RS&I code 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g., gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation) with professional component modifier -26 would therefore apply," he says.