Gastroenterology Coding Alert

Hint: Stick to reporting E/M for removals without replacements.

When your gastroenterologist removes or replaces a gastrostomy tube, you’ll have to discern other services provided and note guidance used to decide upon the appropriate CPT^® code to report for the procedure.

Only Removals? Look Towards E/M

In many instances, your gastroenterologist will only remove a gastrostomy tube during a routine office visit and will not perform any other procedure during the visit. When this is the case, you’ll need to look at whether your gastroenterologist provided E/M services and select an appropriate established patient E/M code (99212-99215). You don’t have to report the removal procedure separately, as this service is included in the E/M code.

But, in certain situations, your gastroenterologist might not be able to remove the gastrostomy tube with usual traction application. In such a scenario, your gastroenterologist might opt to cut the visible portion of the tube as close as possible to the stomach and then perform an upper EGD procedure to remove the remaining bit. When this is the case, you’ll report the endoscopic part of the procedure with 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body). You will not report your gastroenterologist opting to cut the visible portion of the tube with any separate CPT^® code.

Caveat: Don’t report a routine removal of a gastrostomy tube with 43247. You’ll use the code only if the procedure involves your gastroenterologist performing an endoscopy to remove the remaining portion of the tube.

Look for Guidance Used During Reinsertions

Your gastroenterologist will want to replace a gastrostomy tube in situations where the tube is clogged or the gastrostomy tube tract has become infected. He might want to reinsert a previously placed tube if the tube has dislodged or he might insert a new balloon gastrostomy tube through the established tract.  If the procedure involves only replacement or reinsertion of a tube without the use of any fluoroscopic or endoscopic guidance, you’ll have to report the procedure performed using 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance).

If your physician uses a fluoroscopic aid to guide the gastrostomy tube change, you’ll need to report the procedure with 49450 (Replacement of gastrostomy or cecostomy [or other colonic] tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) instead of 43760.

Note: When your gastroenterologist performs change of a duodenostomy tube and a jejunostomy tube, you cannot report it with 49450. Instead, use 49451 (Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) to report this and 49452 (Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) when the tube your clinician replaces is a gastro-jejunostomy tube.

Append Modifier for Replacement During Global Period

If your gastroenterologist places a gastrostomy tube and there is some complication later in the day after the placement that necessitates a change of the gastrostomy tube and the patient is returned to the operating room, you’ll have to report the change of the tube with the modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period) to the replacement code. 

Rationale: “There is zero day global period for Percutaneous Endoscopic Gastrostomy tube placement (43246 – Upper gastrointestinal endoscopy with directed placement of percutaneous gastrostomy tube,aka PEG),” says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT^® Advisory Panel.  “For a gastrostomy tube inserted with fluoroscopic guidance you would use 49440 (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report).”

Example: Your gastroenterologist places a gastrostomy tube using fluoroscopic aid. On the seventh day after the placement, the tube gets clogged and dislodged from its place. The patient is again taken back to the procedure room and your gastroenterologist removes the old tube and replaces it with another tube.

What to report: You report the placement using 49440. Since 49440 has a 10-day global period, you’ll report the change of the tube with 43760. Don’t forget to append modifier 78 to 43760 to indicate that this procedure was conducted during the global period following the initial insertion.

Capture Placement Codes for Endoscopic Guided Reinsertions

In the instance where your gastroenterologist performs a reinsertion or a change of a gastrostomy tube using endoscopic guidance, you’ll have to note that there is no separate CPT^® code to report a change using endoscopic aid. You’ll have to instead report the same code that you will use for gastrostomy tube placement using endoscopic aid. Report 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) for this service.

Example: Your gastroenterologist sees a patient whose gastrostomy tube broke and became dislodged. Since the percutaneous tract is still not well established, your gastroenterologist decides to perform an EGD to remove the old tube and replace it with another endoscopically- guided gastrostomy tube. Since there is no replacement code using endoscopic guidance, you’ll report the procedure with 43246.

Be on the Lookout for Other Procedures Performed

Your gastroenterologist might perform other procedures to evaluate or de-clog a previously placed gastrostomy tube. When your clinician performs these procedures, you have other codes that you can 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
• 49465 — Contrast injection[s] for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy [or other colonic] tube, from a percutaneous approach including image documentation and report

Note: These services include any fluoroscopic guidance used during the procedure. So, any guidance performed should not be reported separately.