Gastroenterology Coding Alert

Reimbursement for percutaneous gastrostomy (PEG) tube placements performed by two gastroenterologists has become more difficult in the past year for many gastroen-terology practices. In response to what seems to be unannounced changes in payment rules at the carrier level, many practices have changed the codes or modifiers they use to report this procedure to ease their payment problems.

PEG tube placement is a multistep procedure that requires two sets of hands. A gastroenterologist performs an upper gastrointestinal endoscopy to locate the desired position along the wall of the stomach for the tube to be placed. Once the position is marked, an incision is made into the wall of the stomach. The PEG tube is then fed over the endoscope and held in place with a retention disk.

While a surgeon or a nonphysician practitioner such as a surgical nurse or a physician assistant can make the incision, it's usually done by another gastroenterologist. At Gastroenterology Consultants, a 10-physician practice in Milwaukee, some of the gastroenterologists feel comfortable working with a physician assistant, while others request another gastroenterologist to perform the procedure, according to Barbara Kallas, billing specialist for the practice.

"The physician assistants are approved to do the procedure by the state, but they don't get separately reimbursed," she says. "We will only bill for the gastroenterologist's services with 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube)." Modifier -62 or -80 The most common way of billing a two-physician PEG placement, regardless of the specialties of the physicians, is for each physician to bill 43246 with modifier -62 (Two surgeons) attached. This is the method recommended by the AMA in the Spring 1994 and February 1997 issues of CPT Assistant. When modifier -62 is used, each physician will receive 62.5 percent of the standard fee allowed by Medicare, according to the Medicare Carriers Manual (MCM) section 15046. Some Medicare carriers, such as California's National Heritage Insurance Company, have indicated that they prefer modifier -80 (Assistant surgeon) when two gastroenterologists perform the PEG placement. The gastroenterologist who makes the incision into the stomach is considered the assistant surgeon, and he or she receives 16 percent of the standard fee allowed by Medicare, according to MCM section 15044. The gastroenterologist who performs the endoscopy bills 43246 without a modifier attached and receives 100 percent of the standard fee allowed by Medicare.

These more restrictive carriers usually allow modifier -62 only when a surgeon is involved. Because PEG placement is a surgical procedure, however, all physicians performing a PEG should be considered surgeons in this situation, argues Sandi Scott, CPC, CORT, director of coding at Mission Internal Medicine Group, a practice [...]