Gastroenterology Coding Alert

Hint: Use same CPT® procedural code for each provider.

Are two-physician PEG tube placement coding challenges tying you down? Appending the right modifier to the procedural code, while taking into account state rules and payer policies, will free you from coding bloopers and reimbursement denial risks.

Procedural example: Your gastroenterologist decides to place a percutaneous endoscopic gastrostomy (PEG) tube in a patient suffering from dysphagia that has caused weight loss over the past six months. Under sedation, your gastroenterologist uses a flexible endoscope to perform an upper gastrointestinal duodenoscopy to determine the site where the gastrostomy tube can be inserted.

Another gastroenterologist places the gastrostomy tube through an incision made in the abdominal wall using the reference of the location determined by the endoscopic procedure. The gastrostomy tube is held in place by a retention disk placed along the anterior abdominal wall.

Coding challenge: When two physicians perform a gastrostomy tube placement using endoscopic aid, you’ll need to know what codes to use to report the work done by each of the physicians.

Code it: Since work done by both the gastroenterologists is part of the same procedure, you should use the same procedural code for reporting the services provided by both of them. "If the physician performs the PEG tube endoscopically, then the code assigned would be 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube)," says Heather Copen, RHIT, CCS-P, Financial Advocate-Goshen OB/GYN and Goshen GI, IU Health-Goshen Physicians, Goshen, Indiana.

Warning: Don’t make the mistake of coding the endoscopic part of the procedure using 43246 and the surgical part using 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report), as both the endoscopy and the abdominal puncture procedures performed are not two individual procedures and are just part of one procedure.

Also, 49440 is used only when the tube placement is done using only a fluoroscopic aid. In addition, Correct Coding Initiative (CCI) edits do not allow 49440 and 43246 to be reported together under any circumstances.

Append Modifier 62 to Your Claims

When reporting a gastrostomy tube placement by two gastroenterologists, you will have to bill 43246 for each of the gastroenterologists. "If two gastroenterologists are required to perform the PEG insertion, you may append a modifier depending on the role of each surgeon," says Linh Nguyen, CPC, Medical Coder - Digestive Care Center, Evansville, Indiana. You will need to append the modifier 62 (Two surgeons) to both the claims in order to help the payer identify that there were two gastroenterologists involved in performing the same procedure on the patient. "You can only assign this modifier if both are working as primary surgeons and performing distinct/separate parts of the same procedure," reminds Nguyen.

To use modifier 62, each surgeon must perform a distinct part of one procedure and must account for that operative work by appending modifier 62 to the code that best represents the service provided. "Typically with co-surgery each surgeon will dictate his/her specific part of the procedure separately so documentation is very important to assigning the correct modifier," says Copen. Each of the gastroenterologists will receive 62.5 percent of the Medicare Physician Fee Schedule Database fee indicated for the procedure.

Reminder: The rules about when you can and can’t use modifier 62 may vary by state, so be sure to check your state regulations and your individual payers to see if modifier 62 is right for your practice.

Know When to Use Modifier 80 Instead

In most instances when two gastroenterologists perform a gastrostomy tube placement, one will handle the endoscopic procedural part and the other will perform the surgical part of the procedure. In some circumstances, you will find that one of your gastroenterologists performed the entire procedure while the other assisted the former in prep and treatment of the incision into the abdomen.

In such a case scenario, you can avoid the modifier 62 usage with the CPT® code 43246. Instead, you can report the primary gastroenterologist’s work with 43246 and the assisting gastroenterologist’s work using 43246 with the modifier 80 (Assistant surgeon). "When a surgeon acts as an assistant rather than a co-surgeon it is necessary to attach the -80 modifier to signify assistant surgeon," adds Copen. This will indicate to the payer that the first gastroenterologist is the primary physician and the second gastroenterologist assisted with the procedure.

"It is important to know the difference between co-surgeon and assistant surgeon because reimbursement is different," reminds Copen. When you use modifier 80, the primary gastroenterologist who is performing the entire procedure will receive 100 percent of the Medicare Physician Fee Schedule Database fee indicated for the procedure, while the assisting gastroenterologist will only receive 16 percent of the scheduled fee for the procedure.

Warning: Some Medicare carriers and private payers may specify that you have to code dual-physician PEG tube placement by indicating one physician as the assistant, especially when two gastroenterologists perform the PEG tube placement. "For Medicare, 43246 has a modifier 80 payment policy indicator of 0 (Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity)," says Nguyen. Be sure to check your state rules and payer policies to determine which of the modifiers (62 or 80) you will have to append when two gastroenterologists perform a PEG tube placement.