Gastroenterology Coding Alert

Now that you have tried your hand at coding the scenarios in the quiz on page 3, check your answers against the experts’.

Define GI Tube Types

First, let’s review a few of the different types of gastrointestinal (GI) tubes referenced in the answers:

Gastrostomy tube (G-tube): Tube that passes through the abdominal wall into the stomach. If placed via endoscope, it’s called a percutaneous endoscopic gastrostomy (PEG) tube.

Gastro-jejunostomy tube (G-J tube): Tube with two access ports: a gastric port that leads to the stomach and a jejunal port that leads to the small intestine.

Jejunostomy tube (J-tube): Tube inserted directly into the jejunum, which is part of the small intestine.

Duodenostomy tube: Tube inserted through the duodenal stump to encourage formation of controlled abdominal drainage.

Cecostomy (C-tube): Tube placed at the start of the large intestine, or the cecum, to empty the contents of what exits the small intestine.

Answer 1: Check for Endoscope

To correctly code this scenario, your best bet is 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report). But you need to pay close attention to the procedure details.

CPT^® code 49440 does not include using the endoscope, which is why it’s a better choice than 43246 (Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube). Unlike 49440, 43246 describes placement of a PEG tube, which includes the use of an endoscope, but not fluoroscopic guidance.

The second part of this question is a little trickier. You’ll need two codes to properly code this scenario. “If there is a conversion to a gastro-jejunostomy tube at the time of initial gastrostomy tube placement, you would use 49440 with 49446 [Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report],” explains Jessica Miller, CPC, CPC-P, CGIC, profee division coding manager at Ciox Health in Chattanooga, Tennessee.

Answer 2: Focus on Type of Service

For this, you’ll want to report 49441 (Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report). The detail to pay attention to here is the type of service. If the provider replaces the tube rather than just inserting a new one, turn to 49451 (Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report).

Answer 3: Follow Similar Logic

To code this, use the same logic you did while answering the second question. Use 49442 (Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report) when the provider inserts the colonic tube and 49450 (Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report) when the provider replaces the tube. Note that procedures described in answers 1-3 are usually performed by radiologists, not gastroenterologists.

Answer 4: Spot Imaging Guidance

“For replacement procedures, you’ll want to look for terminology in the notes that indicates what type of tube the patient had, that it was removed, and how the replacement was performed,” instructs Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, documentation and coding education, Olympia Medical in Livonia, MI. For this scenario, look to 43762 (Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract) because no imaging was used, and the notes make no mention of the provider revising the gastrostomy tract.

Note: If the provider replaces a G-tube during initial placement procedure’s 10-day global period, append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period). If done outside of the global period, no modifier is necessary. This applies to the tube codes with fluoroscopic guidance; endoscopy gastrostomy 43246 has a 0-day global period.

Answer 5: Skip Removal Only Coding

When the physician removes any items from a GI tube, you’ll want to report 49460 (Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report).

For the second part of the question, you cannot use a procedure code for when your gastroenterologist simply removes a tube and doesn’t replace it with anything. You’ll instead report an appropriate evaluation and management (E/M) code from 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient … ). Which E/M code you use will depend on the documentation.

Answer 6: Ensure Endoscopy Documentation Support

Sometimes, the provider can’t get enough traction to easily remove the tube. In this situation, you should report the endoscopy with 43247 (Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)). Placement of the new gastrostomy tube would be reported with 43246-59 (Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube; Distinct procedural service) since it did involve endoscopic guidance.

Note: Make sure the notes clearly state the medical necessity of the endoscopy. National Correct Coding Initiative (NCCI) edits state that intubating the GI tract includes subsequent removal of the tube. Because of this, you need to make it clear why the provider had to go above and beyond the standard procedure.

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